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w 24 V. APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA NouA/ 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. Job Address 44 4F City Lot Size PM Owner's Name GFO, L E Address Phone / 33l o .' Contractor P1.6'VD A4;% /A/&y0',D Address : A0,e=t„aS�e_9�—, /41011 License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ _ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM R PAIR ❑ f OTHER ❑ DISTANCE TO-NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. 'PROP. LINE FOUNDATION AGRICULTURE LL OTHER WELL PITS/SUMPS 1 INTENDED USE TYPE OF W/DT E CONSTRUCTION SPECIFICATIONS O ❑ Industrial ❑ Open BottDia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel PacType of Casing Specifications ❑ Public ❑ Other Depth of Grout Seal Type of Grout I I Irrigation � Approx. Surface Seal Installed byRepair Work Done ❑ Type of Pum . State Work Done Well Destruction ❑ Well Diametealing Material (top 50'1 {` Depth FilleF Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION [1 REPAIR/ADDITION i I DESTRUCTION (No septic system permitted if public sewer is J available within 200 feet.) � n 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. LJ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines, f Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I-1 Depth Size Number SUMPS Ll Distance to nearest: Well Foundation } 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 laws, and rules and regulations of the San Joaquin Local Health District. Home owner or licensed agent's signature certifies the foilowing: "I certify that in the performance of the work for which this permit is issued7).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 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 applicant must call for all required inspections.inspections.. )Complete drawing on reverse side. Signed Xr s 25- !iC/13C Title: Date: ROMFITIMENT USE ONLY Application Accepted by 4Date Area p I Pit or Grout Inspection by �( Date Final Inspection by _ Date d Additional Comments: ��d 0 Stk 466-6781 LJ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 635-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY DATE PERMIT'NO. EH 1344IREV.i,ns) X D EH t4-26