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APPLICATION FOR PERMIT t, s - SAN JOAQUIN.LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE„ STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED, .. �I-(Complete in Triplicate) . -r- Application rApplication 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.„ :; .N l Job Address 1L a Q . SO .y r _^J'ou CityeP`YG7p� Lot Size PM pp r. Owner's Name �,�rr ,V C.)UJ /. Address _Phone f _� G Contractor's Name G(l/�'�I vs Z4'q License No. _13'a P / 15�_ Phone TYPE OF WELL/PUMP: I NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ k PUMIP INSTALLATION J0 SYSTEM REPAIR ❑ OTHER 1-1 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. POOP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS ) 11- INTENDED IFINTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ('Domestic/Private I$Gravel Pack ❑ Tiacy Type of Casing Specifications ID Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation ---Approx. Depth Q Eastern "r�Surface Seal Installed by Repair Work Done ❑ Type o f Pump Jrtld H.P.—4 ___ State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') DeptA! Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is 1111 available within 200 feet.) Installation will serve: Residence_ Commercial-_I Other °t Number of living units: �I Number of bedrooms .I i� Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. [J 1 y, J '-> Method of Disposal_ Distance to nearest: Well Foundations Property Line I - LEACHING LINE ❑ Na. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation 4 Property Line DISPOSAL PONDS ❑ °II, t`� 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 SanilJoaquin Local Health District. - Home owner or licensed agent's;slgnature 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." 111 The applicant must call for all required inspections. Complete drawing on reverse side. - Signed X Gtl 'GJ Title:;d]:ke1AS0A.- _ -.Date: .�� ,i FOR DEPARTMENT-USE-ONLY-_ --- - - Application Accepted by ddd Date Area Pit or Grout Inspection by I� Date Final Inspection by Date ieZ Additional Comments: _ ❑ Stk 466-6781 ❑ Lodi II 369-3621 ❑ Manteca 823-7104 ❑ Tracy 635-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1001 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 q FEE AMOUNT DUE AMOUNT REMITTED CC( RECEIVED BY DATE PERMIT"NO. I INFO tCASW + EH 13-24(REV.101831 EH 1428