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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT A a 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 j 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 i Local Health District. Job Address G L Pn Y GAJ IC-A.- N' City Lot Size PM Owner's Name Address�Fc�! ,.m..�• Phone Contractor { Address 2 Licer:se Na. S 5a_T Phon+48 Z36 TYPE OF WELL/PUMP: NEW vAIELL WELL LL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION !$ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK 150--i• SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL - OTHER WELL PITS/SUMPS i INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation W1 Dia. of Well Casing f$ Domestic/Private Gravel Pack ❑ Tracy Type of Casing P.V,a Specifications L1 Public ` ❑ Other Cl Delta Depth of Grout Seal 1 t Type of Grout �n _ I 1 Irrigation k --Approx.`Depth l I Eastern Surface Seal Installed by ALJR Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth - Filler Material (Below 50') _ (� TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIRlADDITION l I DESTRUCTION l I INo septic system permitted if public sewer is 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 table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ r-�, { Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size _ Number SUMPS Ll Distance to nearest: Well ; Foundation 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. 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 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 u call for all equ' inspections. Complete drawing on averse side. Signed X T� Date: FPJ8 DEPARTMENT USE-ONLY Q'{1 Application Accepted by y�z Date r .`�+ Area Pit or Grout Inspection by� i �l/ Date i Final Inspection by � Date ii Additional Comments: �� , �� t%` /S_� 1 s— ❑ Stk 466-6781 ❑ Lodi 3694611 ❑ 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 INFO A DATE pPERMIT'NO. +.EH 13-24{REV.r/H51 DC r�Q� EH 14-26 �.i E.