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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 TYEAR 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 or No. 1862 for we made in compliance with San Joaquin County Ordinance No.549 for sewage ll/pump and the Rules and Regulations of the San Joaquin Local Health District. !'f Lot Size_ PM Job Address 9i✓ G �C a/trQ City — l "dNFit�f3 /tf/�f�G Phone Address Owner's Name6rel �� (l!S) 61r I /' a�� /'1 Gdru� ;r c 4Li 7Iplq Phone '7/' JC214-7Z ,,,t Address rRs47RT License No. Contractor� � TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION Cl SYSTEM REPAIR ❑ 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 ftPntVAN(o W r ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation y Dia. of Well Casing Tracy Type of Casing. EP/VG Specifications �,qF Domestic/Private ,L�Gravel Pack ♦ � ✓� C 1 Delta Depth of Gro Seal Type of Grout FI Public (,ther �,w _ I I irrigation .Approx. Depth I 1 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 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR0kDDITION 1 I DESTRUCTION I I (Nosbetic systhin m permitted if public sewer is avaInstallation will serve: Residence— Commercial f Other Number of living units: Number of bedrooms Water table depth Character of soil to a depth of 3 feet: SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments Method of Disposal PKG. TREATMENT PLT. ❑ Distance to nearest: Well Foundation Property Line t LEACHING LINE CI No. & Length of lines Total length/size 1 FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I 1 Depth Size Number SUMPS El 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 Diltrict. I certify that in the performance of the work for which this permit is issued, I shall not Home owner or licensed agent's signature certifies the following: " 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 call for all re dins ions. Complet drawing on reverse side. Signed X Title: S� "E'� Date: FOR DEPARTMENT USE 0 Y Application Accepted by Date ��~ Area• Pit ol&t Inspection by Data/ /-S GAJ Final Inspection b Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-&385 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 CASH RECEIVED BY DATE PERMIT'NO. INFO ) 1 !/ �g r.EH 13-24 IREV.1/w 51 �C=�� EH 14.26 '"�