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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA ' Telephone (209) 466-6781 i PERMIT EXPIRES 7 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 O inance o.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. fx offtu GUT O /Za7( ZOO �e�ez.J Job Address �> > s�S City �' �° L Size PM Owner's Name GGg ,.� o f /V AddressPhone J U tS Z/t3 Contractor's Name A44'OR-1t-1' ense �� _ Phone TYPE OF WELL/PUMP:--- NEW-WELL- ❑ WELL'REPLACEMENT DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM R AIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANKSEWER LINES �D fi ¢ DISPOSAL FLD. PROP. LINE/�� FOUNDATION yLr— AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIO �� V ❑ Industrial . El Open Bottom ❑ Manteca Dia, of Well Excavation- /� Dia. of Well Casing 7omestic/Private El Gravel Pack ❑ Tracy Type of Casing Specifications 1 ❑ Public ❑ Other 11Delta Depth of Grout Seal Type of Grout ❑ Irrigation if 1. ---Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ' ❑4 Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 C)\ Depthlam 0 Filler Material fBelow 501 TYPE EPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ fNo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial— Other Number of living units: Number of bedrooms F ' • 'Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT, ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE L`:No. & Length of lines Total length/size FILTER BED p Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth I Size Number SUMPS ❑ Distance to! Well'r Foundation Property Line DISPOSAL PONDS ❑ 1.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 I 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." 'Y �r The applic ust 1l for I requed ins ctio's. Complete drawing on reverse side. Signed " Title (N /fit i Date�� 4 r1,0061 FOR DEPART NT USE ONLY ` Vii✓°�`` _ a ! Application Accepted by �. date Area r Pit Grout I ction b � � � ' y v t ate I` Final Inspection by - Date Additional Comments: ❑ Stk 466-6781-- —❑ Lodi 369-3621— ❑ Manteca 823-7104 ^F - ❑ Tracy 835.63% — Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RE�CEIIV�ED BY DATE PERMIT"N0. +EN 3-24(REV.10183) [ �� L.i3 1031 �Y) [0-1V-?9 EH 1428 11 Y