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APPLICATION FOR PERMIT "AN JOAQUIN LOCAL HEALTH DISTR& 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is heieby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application i 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 Joaqui Local Health District. // \\ �� yy�� Job Address ��ly+ � G_ASI 0 L,I , City-J.> Lot Size - PM Owner's NameZ_'E/ CL-h R 1` .� Address Phone Contractor Va l�k 7 tt FtLj Address License No.41 e ?-) Phone-G� TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR 0 OTHER ❑ 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 0 Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑Gravel Pack ❑ Tracy Type of Casing Specifications Fl Public ❑ Other Fl Delta Depth of Grout Seal Type of Grout I I Irrigation _Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done_ C>0 Well Destruction ❑ Well Diameter Sealing Material (top 50'1 017 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I -.PAIR/ADDITION I I DESTRUCTION I I INo septic system permined if public sewer is available within 200 feet.) Installation will serve: Residence 1. ,-Commercial_ Other Number of living units: / Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg - 1 - Capacity/4,� No. Compartments PKG. TREATMENT PLL ❑ Method of Disposal Distance to nearest: Well Foundation-� _ Property Line �� LEACHING LINE Q�n. 8 Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well ^ rFoundation.__ 15_ Property Line SEEPAGE PITS -�epth I Size_ _ Number SUMPS LI Distance to nearest: Well. Foundation Property Line DISPOSAL PONDS ❑ Q 00 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, an rules and regulations of the San Joaquin Local Health DiWict. 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 n employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signatur 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'Cal farm _ The applicant all for II r 'uin Ins a iq ss^. omplete drawing on reverse ide. g �- _ .' " L{i-41i �� Date: "' —1 '" "=-✓ CL,/ Si ne X Title: / FOR DEPARTMENT USE ONLY / r^7 Application Accepted by Date lf/ Area y Pit or Grout Inspection by Data Final Inspection by J•_2_1 /�G - [a� Date J Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 0 Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE NFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. .-EH 13N(REV.vxsr -� EH 13,.2a