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I f i APPLICATION-FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE.,:STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 'I YEAR FROM DATE ISSUED 1, 1r (Complete-in Triplicate): b ._ 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"' nF / �y / /T. ... ..y. s r Job Address 1?yr e`AF S �L f j1IGY Ai C City gGafv Lot Sizex°� P DA 5 4 e-6 Zo _ _ _ 3 L.olrk� Owner's Name G G BGG✓ Address Z 4°' Lis u Phone Z- I Contractor Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ r PUMP INSTALLATION [ SYSTEM REPAIR ElOTHER El I 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/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation ' --Approx. Depth ❑ Eastern Surface$ al Insa IV by ` Repair Work Done ❑ Type of Pump H.P. 7� �/ State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 204 feet.) Installation will serve: Residence Commercial_ Other, Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK - 17 —TYpa/Mpy _ No. Compartments PKG. TREATMENT PLT. O ` � i� Method of Disposal }.. Distance'to nearest: Well Foundation Property Line i i LEACHING LINE' ` '_ -No. & Length of lines Total length/size FILTER BED. .O`'Distance to nearest: WeII' Foundation Property Line SEEPAGE PITS ❑ Depth '—'---Size Number SUMPS w, ❑, Distance to nearest: "*:-Well - 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 District.- 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."Contiactor's hiring or sub-contracting signature certifies the following: '!f-certify 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." ' The-applicant must a il,for all r uire ction . C mplete drawing on reverse side. sign 11 X Title: Date: FOR DEPARTMENT USE ONLY i Application Accepted by L/� � f " " '" Date Area Pit or Grout Inspection by Z date Final Inspection b Date %, Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 XManteca 823-7104 ❑ Tracy 835-6385 i Applicant - Return all copies to: Environmental Hea h Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95241 FEE E INFO AMOUNT DUE AMOUNT REMITTED-- CK RECEIVED BY DATE PERMIT-NO. i+ EH 13-24 IR:V:l i'a 5)