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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 'I'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. r� Job Address �� 1 e. [�f� _---- -- City S C �6_0Lot Size PM Owner's Name S�Gr/G l�rfl Address „S� en Phone Contractor -_ _��tiC Address b L'scense No. �•?SSrS� Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ 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 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications I-1 Public 171 Other ❑ Delta Depth of Grout Seal Type of Grout _ E I Irrigation Approx. Depth I I 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 50') TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ( I DESTRUCTION € I (No septic"sy'stem permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial_ Other Number of living units: _A_ Number of bedrooms Character of soil to a depth of 3 feet: _,2;c rut V C{Q y _ Water table depth SEPTIC TANK 1PI'-Type/Mfg _ GCS C-{ Capacity_ No. Compartments PKG. TREATMENT PLT. F-I ��-- f Method of Disposal Distance to nearest: Well Foundation 1-0 Property Line_ LEACHING LINE FI/No. & Length of lines Total length/size L Ci FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS fy Depth Size Number a SUMPS Cl Distance to nearest: Well Foundation CS/ Property Line DISPOSAL PONDS Cl -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 Di§trict. 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 taws 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 must call for all requir d ins actions. Complete drawing on reverse side, Signed X 1 Title: Date: FOR DEPARTMENT USE ONLY _ Application Accepted by _ r"r Date Area Pit or Grout Inspection by bate anal Inspedtion by i"^ Datez 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 INFO AINOUNT DUE AMOUNT REMITTED CASH CK 6 RECEIVED BY DATE PERMIT'NO, r + Q EH 14.26 EH 13-241REV.r/a51 '• �