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S APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE.T ON AVE., STOCKTON, CA " Telephone (209) 466-6781 PERMIT EXPIRES 1 YEARFROM DATE ISSUED tComplete in Triplicate) Application is heteby 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. I' Job Address CityGL Lot Size PM Owner's Name gueGAALAdclress ,z/ Y_ Phone f Contractor_ /4►.�� E _Address a` License No. 02�' Phone ' TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT LiDESTRUGTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ i OTHER❑ . DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL F,LD. PROP. LINE FOUNDATION t AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL ## PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial / ❑ Open Bottom q ❑ Manteca u 'Dia. of Well Excavation i Dia. of Weil Casing r I El Domestic/Private y' 0 Gravel Pack ❑ Tracy Type o Casing Specifications- F1 Public !`[ n Other ❑ Delta -Depth$f Grout Seal Type of Grout _ ,l ; I I irrigation --Approx. Depth l 1 Eastern '`•Surfac Seal Installed by - i . State Work Done Repair Work Dane ❑ �!! Type of Pump � H.P.HP•s��- .• i Well Destruction ❑ i Well Diameter ; SealingViaterial Itop 50'1 Depth Filler�Niferial IBJ ow 50'1 1 TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/A DITION i-„ DESTRUCTION I I (No 'septic system permitted if public sewer is rt Y /t available within 700.feet.) Installation will serve: Residence Commercial _ Other.. Number of living units: —/—' Number of bedrooms , Character of soil to a depth of 3 feet: .d n-'6 Water table depth SEPTIC TANK ❑ Type/Mfgi =Zrapacity ___ No. Compartments; C PKG. TREATMENT PLT- ❑ - � Method of Disposal Distance to nearest: r Well - 'F&n&ion_ , Property Line ` A 1� �` � �a Total len the• LEACHING LINE � No. &Length of line ' /siz s' 9 , FILTER BED ❑ Distance to nearest: Well ' FoundationProperty Line ! SEEPAGE PITS l I Depth Size ' _ Number SUMPS ❑ Distance to nearest: Well FOUn�ation Property Line DISPOSAL PONDS ❑ -'"' t "`" l 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 District. ] Home owner or licensed agent's signature certifies the following: "I certify-that in the performance of the,'work for which this�ermit is issued, I shall not employ any person in such manner as to become subject to workman's compensation=laws of California."Contractors hiring of sub-contracting signature certifies the following: "I certify that in the performance of the work'for which this permit is issued,l shall employ persons subject to workman's compensa- tion laws of.California." The applicant must call for all requiryd inspec' ns. Com Iota drawing on reverse side. i • 1 s E- 9 � Signed X Tale; __4!et - , Date: i I FOR DEPARTMENT USE ONLY ` ' ,�'� �~ Area J Application Accepted by Date I p Pit or Grout Inspection by Date Final Inspection by Date �7 Additional Comments: ❑ Stk 466-6781 ? El-Lodi 369-362:1 ❑ Manteca 823-7104 ❑ Tracy, 835-6385 1 t, Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Bax°2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE j PERMIT•NO. INFO CASH +SEH 13-24 IREVit/x 51 EH 14.26