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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone 1209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 4 (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. ab Address GL y ti, t1 CityJ t ._ � Lot Size -le-/2 0 PM f I Sp Owner's Name l - 01"Gri IJ !& Address J Phone <►°`�/ Contractor Address License No. Phone J TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP-INSTALLATION ❑ - - SYSTEM REPAIR-0 - - OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. 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 LlOther i ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 1� Depth I Filler Material (Below 501 lJ) TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION D�JNo septic system permitted if public sewer is + available within 200 feet.) �l Installation will serve: Residence Commercial_ Other Number of living units: t Character of soil to a depth of 3 feet: "Water fable depth 1 SEPTIC TANK ❑ Type/Mfg --Capacityy No. Compartments PKG. TREATMENT PLT. ❑ I Y Method of Disposal f 1 Distancetonearest: Well Foundation Property Line t LEACHING LINE ❑' No. & Length of lines Total length/size i FILTER..BED___ E1.-_Distance to nearest:.,,,, -Well Foundation Property tine SEEPAGE PITS ElDepth Size Number SUMPS ❑ Distanceto nearest: Well Foundation Property Line ' DISPOSAL PONDS T ❑ 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."Contractor's hiring or sub-contracting signature certifies the following: "I 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 m t II for all required,ins s plate drawing on reverse side. Title: DEPARTMENT +-- Dater Signed �) DEPARTMENT USE ONLY Application Accept by Date rrl � Area Pit or Grout Inspe y Date Final Inspection by r f Data 3 Additional Comments: ❑ Stk 466.6781 ❑ Lodi 369-3621 ❑.Manteca 823-71104 0,Tracy 835-6385 Applicant .Return all copies to: Environmental Health Permit/Services 1601 E. azelton Ave., P.O. Box 2009, Stk., CA 95201 t _ . FEEi INFO AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT N0. t ..+EH 18-24(REV.I/&51 EH 14-26