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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON ON AVE., STOCKTON, CA Telephone (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. 549 for sewage or No. 1662 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. t `� JVGA475- Job Address City C-a D Lot Size t, PM Owner's Name W• 1; WWI � � Address 13'Yt 'IF�� !qc X Phone r'3 j- .3 Contractor R a Address 1 License NQ. i Phone TYPE OF WELL/PUMP: NEW WELLO WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALtJATION ❑ SYSTEM REPAIR ❑ v OTHER El 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' D Manteca 4 Dia. of Welt Excavation Dia. of Well Casing Pr5omestic/Private 0 Gravel Pack ❑ Tracy ,Type of Casing Specifications � R Public ❑ Other F1 Delta Depth of Grout Seal Type of Grout _. r I I Irrigation Approx, Depth i I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. r State Work Done Well Destruction ❑ Well Diameter Sealing Material Stop 501 (/v� i Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION PFIRZETPAIR/ADDITION l Ir DESTRUCTION l (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residenceommerciai— Other Number of living units: --I— Number of bedrooms S Character of soil to a depth of 3 feet: Sa-_�C6ewL, Water table depth T r SEPTIC TANK ❑ Type/Mfg A+C CAST CO3rC AT- Capacity 1b©® GYFL No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well //0f/Foundation Property Line ' LEACHING LINE Cl No. & Length of lines 1 AWfr "` � !EtTotal length/size FILTER BED ❑ Distance to nearest: Well11 o Fouridation Property Line SEEPAGE PITS I I Depth S�rEj= Size L^C- y Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ µ _ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state JaWs, 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,]shall not I 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 required inspections. Complete drawing on reverse side. Signed X Title: Date: __ FOR DEPARTMENT USE ONLY Application Accepted by G" - Date 7 Area r� it r Grout Inspection by Date. Final Inspection by Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 CJ 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 0 RECEIVED BY DATE PERMIVNO. >; INFO CASH +.EH 13-21(REV.t i x 5) L �O f} Q ;L/ e� ! tJ / Jf/ J// . EH 11-26 (J