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APPLICATION.FOR PERMIT ± SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA x 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. ,�-+ ]] _ P (J Ile ,�1 r1� City L--D Lot Size PM Job Address r Owner's Name �- Address IJ GL&Uo j! — Phone _ Phone Contractor's Name _ License No. �y 7-� TYPE OF WELL/PUMP: NEW WELL El WELL REPLACEMENT LJDESTRUCTION LJ 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 Dia. of Well Casing El industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Specifications ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing EJ Public L3 Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction 0 Well Diameter Sealing Material {top 501 Depth Filler Material {Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION L�YDESTRUCTION ❑ (No septic system rmtted if public sewer is Installation will serve: Residence Commercial Other Number of living units: I Number of bedrooms y Water table depth Character of soil to a depth of 3 feet: SEPTIC TANK ❑ Type/Mfg Capacity Gadd No. Compartments Z PKG. TREATMENT PLT. El of Disposal Distance to nearest: Well Foundation Property Line 07. LEACHING LINE ®'No. & Length of lines r Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line Size SUMPS Number t SEEPAGE PITS �Depth 7 SUMPS E:1 Distance to nearest: Weil r Foundation r— Property Line ' DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state)aws, 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 compensationilaws of California."Contractor's hiring or sub-contracting signature certifies the following: 111 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 call for 1 requi d inspections. Complete drawing on r/ejverse side. 3 �A Signed Title: —(L l(, x�Cd��.- ' Date: . FOR DEPARTMENT USE ONLY Data Area - Application Accepted byr I C %C�/ Pit or Grout Inspection by Date �` "I Final Inspection by Date_ 7 Additional Comments: ❑ Stk 466-6781 ❑ LodP-369-3621 - ElManteca-823-7104 ❑ Tracy 835 5385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 35201 FEE CK RECEIVED BY �A.TE PERMIT"NO. INFO AMOUNT DUE AMOUNT REMITTED CASH +EH 13-241REV.101831 / EH 14-28 Q O