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APPLICATION FOR PERMIT SAN JOAQUIN LOCACHEALTH DISTRICT 1601 E. HAAL-1ON'AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Ryles and Regulations of the San Joaquin Local Health District. J" Job Address City LotSizePM Owner's Name lGLra Address1- T Phone 33y /1 Contracugi,2c1,14Address ! .- ?!K License Phone. �© TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing —❑.Domestic/,P.rivate—❑.Gravel-Pack ._, - --D-Tracy-- . ._ .Type of Casing _.Specifications w ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation ---Approx. Depth ❑ Eastern -Surface Sell Installed-by` -\J Repair Work Done ❑ Type of Pump H.P. State Work Done -Well_Qestruction__ _❑___Well-Diameter_ Sealing.Material_(top_50'1 _ Depth Filler Material {Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other 7�-A.&O Number of living units: Number bedroo Character of soil to a depth of 3 feet: Water table depth d SEPTIC TANK C Type/Mfg Capaci. 4= No. Compartments PKG. TREATMENT PLT. ❑ f r Method of Disposal Distance to nearest: Welles FoundationProperty Line LEACHING LINE ❑ No. & Length of lines Total length/size j r ii r FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Sie Sd Number f i SUMPS 2"'Distance to nearest: Well ! Foundationi �/!�' Property Line DISPOSAL PONDS ❑ E I hereby certify that I have prepared this application and that the work will be done"in accordance with San JoagVin county ordinances, state laws, and rules and regulations of the San Joaquin Local Heaith District. / 4 - Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." Contractors hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work far which this permit is issued;I shall employ persons subject to workman's compensa- tion laws of California." The applican ust call for I re ire d inspections. Complete`drawing on reverse side. Signed Title: FOR DEPARTMENT USE ONLY i plication Accepted by Date7. al or Grouf Inspection b ate J Final Inspection byat� �J Additional Comments: ❑ Stk 466-6761 ❑ Lodi 369-3621 ❑ Manteca 823-7104 LJTracy 8354M y �f Applicant- Return all copies to: Environmental Health Permit/Services 160f E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED-8YDATE PERMIT'NO. 1 0 CASH-- — r EH 13-24(REV.1/9 sl -A" '•'``� `a'it 4 "'" 'r 4 -" 1-7, EH 1426