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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON 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 ! GSI l �t' r✓ /'�1� City 414/2- 015-L-ot Size PM Owner's Name ,Z �Z � &e/Address Phone Contractor's Name l ? d ? License No: c ��'— Phone TYPE OF WELL/PUMP: r NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ E"5 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 ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ 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 Depth Filler Material (Below 501 e TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is A available within 200 feet) Installation will serve: Residence✓ Commercial_ Other Number of living units:--_-._- Number of bedrooms Character of soil to a depth of 3 feet: Water Water table depth SEPTIC TANK 59r'T e/Mf Cwt cr_ yp g F7 � Capacity LY41+fir No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE Ee No. & Length of lines L Total length/size / FILTER BED ❑ Distance to nearest: Well Foundation _ Property Line T SEEPAGE PITS ❑ Depth i f Size Number f� SUMPS M"Distance to nearest: Well 196 Foundation 101 J— Property Line DISPOSAL PONDS ❑ 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. I 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 l 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 mus call for all required jnppections. Complete drawing on reverse side. Signed �� i72✓. _(Y ._� -f �r Title: ' Date: FOR DEPARTMENT USE ONLY Application Accepted by �� Date Area Pit r Grout inspection by` Data Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ 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 AMOUNT DUE AMOUNT REMITTED CK# RECEIVED BY DATE PERMIT'NO. INFO CASH + EH 13-24{REV.10!83) �S EH 14-26 O�"1