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APPLICATi6N FG-1t PERMIT � �,�` SAN JOAQUIN LOCAL HEALTH DISTRICT s'• y `J 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 1 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED eeooc, `� (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 Reg uta�ions%of'the San Joaquin Local Health District. Job Address / 41_—t GL d L City --Lot Size PM Owner's Name Address. '~` Phone I Contractor, Address, 5�/ Zrlal License N � Q Phone I TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ r 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 IXDomestic/Private ❑ Gravel Pack ❑ Tracy , Type of Casing Specifications F1 Public ❑ Other Cl Delta ". Depth of Grout Seal Type of Grout I I Irrigation �._Approx-..Depth l I Eastern Su ce Seal Instaliud by Repair Work Done ye Type of Pump _ � H,P. State Work Done/,16w—� Well Destruction ❑ Well Diameter Sealing Material Itop 50'1 Depth Filler Material {Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ['I REPAIRIADDITION F I DESTRUCTION I IINo septic system permitted if public sewer is L4 ,r available within 200 feet.) Installation will serve:- Residence_ Commercial_ Other 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 O LEACHING LINE l ❑ No. & Length of lines Total'length/size [[� FILTER BED ❑ Distance to nearest: Well Foundation Property Line -I f SEEPAGE PITS 1 l I_ Depth Size ` Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS } ❑ hereby certify that I have prepared this application and that the work will be done in accordance with Sart Joaquin county ordinances, state laws, 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, 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 I 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 applic -call for all required ctio . Co to drawing on r rse side. Signed X Title: _- rS�r Date: 19 z4 FQR ARTMENT USE ONLY Application Accepted by Date z Area Pit or Grout Inspection by' Date Final Inspection by °`t Date6� 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' INFO CASH NO. +.EH 13-24{NEV.1/K 5) S �v V EH 14-26 i