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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. 'NAZELTON 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 Rules and Regulations'of the San Joaquin Local Health District. Job Address 60q �� QC�c �o vI City Lot Size. & X l7 7 PM UZ Owner's Name �O� G EH Address -� Phone r 14tod��t Ca 953 6 Gro1j Contractor 8 r'!t"> S Bvt S. AddTeSSIIEVLicense No._2-9Ofir/_3 —1 Phone TYPE OF WELL/PUMP: NEW WELL ❑ . WELL REPLACEMENT ❑ `DESTRUCTION,fg: , PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE,TO-NEAREST: SEPTIC TANK, SEWER LINES _,T0 4�+ DJSPOSAL..FLD._At/Z1_9 _PROP. LINE FOUNDATION AGRICULTURE WELL ti/4 OTHER WELL PITS/SUMPS 1q 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 I'l iPublic ❑ Other r _ Y =~ (=l Delta Depth of Grout Seal Type of Grout — I I Irrigation ____.-Appy& Depth's I I Eastern Surface Seal Installed by - Repair Work Done ❑ Type of Pump L H.P. State Work Done _ k Well Destruction ;9 Well Diameter __.1 Sealing Material (top 501 Depth_ ; `£70 Filler Material (Below 50') �' n J„Y PE OF SEPTIC WORK: NEW INSTAL4ATION I 1 WREPAIR/ADDITION I 1 DESTRUCT, 6 septic system permitted if public sewer is . available within 200 feet.) `Installation will serve: Residence_ Commercial= Others...__. Number of living units: Number Of bedrooms Character of soil to a depth of 3 feet: Water table depth ,• SEPTIC TANK., ❑ Type/Mfg`' .- Capacity No. Compartments PKG—TREATMENT PET' ❑ 4 Method of Disposal Distance to nearest:'—""W4IIT' Foundation Property Line k LEACHING LINE ❑ No. R Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I 1 Depth Size Number SUMPS Ll Distance to nearest: Well_ Foundation Property Line DIbPOSAL PONOS ❑ ---- 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 Di1trict. 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 follow'��g: "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 Calif rnia"I The app'cant rp4st call for all required ' ctions. Complete drawing n reverse, id Signed X � Tit1e: � Date: FOR DE PAR ENT USE ONLY Application Accepted by Date//1Z Tv Area } Pit or Grout Inspection by to Final Inspection by Date 7- t Additional Comments: ❑ Stk 466-6761 ❑ Lodi 369-3621 ❑ Manteca 623-7104 ❑ Tracy ;835-6385 -° Applicant - Return all copies to:'Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 w FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. ;. n��-. INFO 1 . +.EH 13-21(REV.t/n5) � �� " �'�3 f31� EH 1 4-26