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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT i 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED s (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 Ryles and Regulations of the San Joaquin Local Health District. Job Address i X CityOo,(—." Lot Size PM Owner's NameCj,.G4AL /; Cl, �p . Address Phone � /2 Contract 161 Address f?'i /n / CR'W License No.1Z GZc��r Phone TYPE OF`WELL/PUMP: NEIN WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION_❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER'LLINES DISPOSAL FLO, i '` 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 WelllCasing ❑ Domestic/Private li"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 ry Repair Work Done ❑ Type of Pump H.P. State Work Done:I yl J t .Well Destruction F) Well Diameter r Sealing Mater ial (top 50'1LV •" Depth Filler Material (Below 501 'I� FTYPE OF;SI PTIC WORK:,. NEW INSTALEATION Ur REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic s"ystem permittedlif public sewer is available within 200 feet.) t Installation will serve: Residence_ Commercial Other Number of IiVing units: Number f edro ms `` Character of`soil to a depth of 3 feet: Waterltable depth C5 :SEPTIC TANK Type/Mfg C Capacity e{ I o o No. Compartments .PKG. TREATMENT PLT. ❑ i Method of Disposal Distance to nearest: Weil d� Foundation l� Property Line -- i f ;LEACHING LINE Cdr No. & Length of lines `Total length/size 420 X' FILTER_BED ❑ Distance to rjearest: Well In 6 Foundation_�/�. Property Line 4'•' 'SEEPAGE)PITS W .Depth ac,, Size'_ 7 Q Number 12) i SUMPS ❑ Distance t0 nearest: Well Foundation ` Foundation �G° Property Line_ ; +DISPOSAL PONDS ❑ p + 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." k iThe applicant must call for all required inspections. Complete drawing on revTrso`}side. Signed X Title: , �C y )n44, s Date: FOR DEPARTMENT USE ONLY -A lication Accepted b� ✓ PP p Y Date Area PI or Grout Inspection by Date Final Inspection by Date 1 l 'Additional Comments: Stk 466-6761 0 Lodi 369-3621 0 Manteca 823-7104 ❑ Tracy 8355-6385 -.Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 85201 FEE AMOUNT DUE AMOUNT REMITTED CK# RECEIVED BY DATE _ PERMIT'N0." INFO CASH'— +EH13-24(REV,i/ae7 _ c '. 16L { EH IA-C, O iF