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APPLICATION FOR PERMIT 41,K SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON 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. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. AA 33 Job Address LOU . City W Lot Size PM Owner's Name ^ Address GL? ��'�'=— J We aj T Phonu Q Contractor v Address License NoI(e 1 73 Phone TYPE OF WELL/PUMP:,,,, �. NEW WELL ❑- , WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION.91 SYSTEM REPAIR ❑ OTHER ❑ _ DISTANCE TO NEAREST: SEPTIC TANKSEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCI ION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing '*Domestic/Private- -❑ Gravel Pack ❑ Tracy Type of Casi g Specifications' ❑:Public y ❑ Other 1-1 Delta f.. Depth of Gro t Seat Type of Grout I I Irrigation --Approx. Depth,{ t I,E6astern S ace Seal'Installed by C Repair Work Done ❑ Type of Pump - H.P. State Work Donera.c.i, Well Destruction ❑ Well Diameter Sealing Material (top ) Depth f=iller Material (Below ) TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I i DE TRUCTION I I (No septic system permitted if public sewer is available within 2W feet.) Installation will serve: Residence_ Commerci I'_ Other Number cf�-living units: Number of bedro s Character of.soil to a depth of 3 feet: _Water table depth SEPTIC TANK- -❑; T - ._ Type/Mfg CapaItY No Compartments PKG. TREATMENT'P.LT. ❑; - t- Method of Disposal Distance to nearest: Well Foundation Property.Line LEACHING LINE;, ❑ No. & Length of,lines Total length/size FILTER BED ❑ Distance to.nearest: Well Foundation Property Line I SEEPAGE PITS t�Al I Depth Size G Number SUMPS ❑ Distance to nearest: Well Foundatio I Property Line t DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will be done i accordance with San Joaquin county ordinances, state laws, and I rules and regulations of the San Joaquin Local Health District. Home owner or licensed agent's signature certifies the following:"I certify that in th performance of the work for which this permit is issued, I shalt not employ any person in such manner as to become subject to workman's compensations 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." j The applicant�t c for alt req fired inspections. Complete}drawing on reverse sidle. ] G Signed Xy)lfi[ tle: Date: - _ i .6. ,jFO. RTMENT USf ONLY r' I Application Accepted by Date / Area Pit or Grout Inspection by Data Final Inspection by at�� Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy;- 835-6385 I. Applicant - Return all copies to: Environmental.Health Permit/Services 1601-E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 i u FEE INFO AMOUNT DUE j AMOUNT REMITTED CK 9 CASH RECEIVED'BY DATE PERMITNO. '�'� 3 ♦.EH 13-24/REV.)/a 5) 3 S- 00 '