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APPLICATION FOR PERMIT ,- G SAN JOAQUIN LOCAL HEALTH DISTRICT l 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 ` PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) i 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 r 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. Job Address ;2 S7�LUAP T 5 T ,, City Vie✓ Lot Size PM Owner's Name G,e r—n SS Address __ 4 ' AE Phone Contractor d5—"YD E. AJW i7 Address Gds`Al. LICLiA itl AV-- License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ i PUMP INSTALI•;ATION"❑' —'——SYSTEM'REPAIR"❑I OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS j INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS FN ❑ Industrial ❑ Open Bottom ❑ Manteca pia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing i Specifications ❑ Public ❑ Other j ❑ Delta Depth of Grout Seal I. Type of Grout F ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done `tet Well Destruction ❑ Well Diameter Sealing Material (top 50'1 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTiONX(No septic system permitted if public sewer is i ✓ available within 200 feet.) Installation will serve: Resi nce Commercial_ Other f Number of living units: Number of bedrooms Character of soil toad th of 3 feet: ' Water table depth SEPTIC TANK ❑ Type/Mfg Capacity-1— No. Compartments ' PKG. TREATMENT PLT. ❑ °;try Method of Disposal Distance to nearest:",: Well ( Foundation ' ` Property Line ' LEACHING LINE ❑ No. & Length of lines_ !Total length/size ' a o , FILTER BED ❑ Distance to nearest: Well—.__.. Foundation Property Line SEEPAGE PITS ❑ Depth _Size/- ' - Number SUMPS ❑ Distance to nearest: Well 1 Foundation R Property Line r DISPOSAL PONDS ❑ ! i i 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 Icompensation 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." j {r The applicant must coil for all required inspections. Complete drawing on reverse side. t Signed s • 'lNa Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by Date' Area Pit or Grout Inspection by Date Final Inspection try Date V Additional Comments: y-3S./ f ,�O -s7__ �iCcGLri ✓ s.,.?. 17 L � ,`+;) ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 1823-7104; ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Bax 2008, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED C RECEIVED BY DATE PERMIT'NO. INFO {' C H + EH 13 REV.i/s E) 1 ` /6110 3 EH 1428 lll)))I CCGAA < (/�!