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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephotie (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. 548 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address 24531 N Graham Rd City Lot Size PM Owner's Name BILL OA RR ISDN. Address Phone Contractor GQEHR N PUMP AddresBOX 113 LockefOr- License No. 309x31 Phone - TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR U 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 AftEA--�GONSTRUCTION-SPECtFICAT#ONS - ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 1'1 Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout I I Irrigation Approx. Depth I ) Eastern Surface Seal Installed by - Repair Work Done RAX Type of Pump 1 Y, H.P. __SxUb State Work Donei nStal lod IMPmel"S1 le Well Destruction O Well Diameter Sealing Material (top 50') Depth Filler Material (Below 501 - TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION t I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial, Other LA 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. ❑ 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 I I Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that t have prepared this application and that the work will be done in accordance with San Joaquin county oIstate rules and regulations of the San Joaquin Local Health District. Home owner or licensed a is 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 su.96 p6anner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies t4mr rtify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws The appliI squired inspections. Complete drawing on reverse side. Signed X Title: Date: _ 06,129.189 FOR DEPARTMENT USE ONLY Q Application Accepted by `�( '� -� ' Date t' Area Pit or Grout Inspection by Date_ Final Inspection by 4 <4QL Date -1�-��' 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 /r +.EH 53-24{REV,I/H 51 �r / EH 14-2e