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I i a77 APPLICATION FOR PERMIT ' SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED f (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 Rules and Regulations of the San Joaquin Local Health District. L i Job Address City Lot Size 2 PM Owner's Name _(��' GUlff/`L/l�! ��Agddress Phone ContraAddress_ctor -� I�I/l GE ��f e7C L. r�r•ense No��h�Phone — I TYPE OF WELL/PUMP: NEW WELL�ff_ WELL RE ACEMENT. LJ-,,, m. DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ - OTHER DISTANCE TO NEAREST: SEPTIC TANK 4'JJ= SEWER LINES DISPOSAL FLD f _+—PROP. LINE FOUNDATION -. _ A GRICULTURE 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 -JA-Domestic/Private �ia Gravel Pack ')?LTracy Type of Casing Specifications Fl Public Cl Other 11 Delta Depth of Grout Seal Type of Grou __ i I Irrigation bf)_,Approx. Depth l I Eastern Surface Seal installed by Repair Work Done fJ Type of PumpH.P. Slate Work Done_ Well Destruction ❑ Well Diameter Sealing Material (top 50') _n Depth Filler Material (Below 501 (\l TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I 1pESTRUCTiON I ] tfJa septic system permitted if public sewer is U' Installation will serve: Residence_ Commercial available within 200 feet.) Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: } Water table depth SEPTIC TANK ElTypelMfg Capacity No. Compartments � + PKG. TREATMENT PLT. ❑ Method of Disposal Distance 10nearest: Well--Y_ .Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS ❑ Distance to nearest: Well F Foundation _ Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health Driltrict. I 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 1 employ any person in such manner as to become subject to workman's compensation laws of California." Contracto'r's hiring or sub-contracting signature certifies the following: "I c rtify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." 1 The appli m I r all r uired-ins ctions. Complete drawing on r rse side. i Signed X Title: Date: j Y __ FOR DEPARTMENT USE O Y 1 Application Accepted by Get Date r /(1 T Area Pit or Grout Inspection by Date Final Inspection by mate f� f v - Additional Comments: Ll Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 t ' FEEIi INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. + EH 13-24[REV.riKsl 4 EH 14-26 1 4