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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL-.HEALTH DISTRICT 1601 E. HAZE i ON AVE., STOCKTON, CA Telephone {209} 466-6761 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED # (Complete in Triplicate): k ? 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 I 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. ' "''"— ` ' T' - — � r Lo' a Job Address _�5" City BGG Lot Size PM F Owner's Name 'v c' CJ' Address P nea Phone Contractor 4 , " u G G Address License No � �� Phone 8� TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ I SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK H� SEWER LINES_ DISPOSAL FLD_ _ P,ROP..LINE_ FOUNDATION AGRICULTURE WELL - �-v OTHER WELL PITS/SUMPS INTENDED USE ITYRE OF WELL_ PROBLEM AREA_,.CONSTRUCTION SPECIFICATIONS ❑ Induitrial O Open Bottom ❑ Manteca Dia. of Well Excavation . «w Dia. of Well Casing i ID ❑, Gravel Pack ❑ Tracy Type of Casi g 9� "'�_t Specifications ❑ Publ is If Other ❑ Delta D pth of Grout Seal ;Type of Grout ❑ Irrigation pp►ox..Depth ..❑"Eastern- Surface Seal Installed by" '— Repair Work Dane ❑ Type of Pump H,P. State Work Done f Well Destruction ❑ Weil Diameter-4 Sealing Material ttop 501 Depths' 1 ,Filler Material (Belo,50:) �t TYPE OF SEPTIC WORK: NEW INSTALLATION 4,x REPA)R/ADDITION ❑,,,,DESTRUCZION��Woseptic system,permitted if public sewer is �' }' b available within 200 feet.) Installation will serve: Residence d_ Commercial Other Y Number of living units:—1 Number of bedrooms"' Character of soil to a depth of 3 feet: - is `�,, A v 1 Water table depth i fh SEPTIC TANK ❑ Type/Mfg a`— + y�._y Ga""�acitye No. Compartments PKG- TREATMENT PLT. ❑' W t' j * r .Distance-to nearest: Well`T'=F k � Method of Disposalt.- Foundation Property Line ` 'LEACHING LINE Length of linea Total length/size' FILTER BED LJDistancekto-nearest: —Weill Founda ll 4 tion�? " � �� " s I, � �-y`"-�Proprerty Line SEEPAGE PITS O` Depth "`T~ Size [ Number SUMPS -,_ �Q s Distance t "Foundati o nearest: Well { i on—'Property line DISPOSAL PONDS ❑ t it v I hereby certify that t 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:0-cern employ an fy-that`in the performance of the work for which this permit is issued, I shall not p y y person in such manner as to-.become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the following: "I certify that in tfte performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." t.- ; The applicant must call for I requd i inspections. Complete drawing on reverse side. Signed e' y Title: 4 > — Date: /(v/. FOR DEPARTMENT USE ONLY Application Accepted by j Date —� U W 9 Area Pit or Grout Inspection by i Date" Final Inspection by Date " 6 k Rdditio l I Comments: ❑ Stk j466-6781 ❑ Lodi 369 3621 ❑ Maniacs 823-7104,,- (racy 835-6385 - k. Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton eft., P.O. Box 2009;Stk., CA 95201 Y FEE AMOUNT DUE/ AMOUNT REMITTED CASH RECEIVED BY INFO DATE PERMIT'NO. F + EH 13.241REV.ii651 EH 1 _ �, 429 " (�' t' ,