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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT �F 1601 E. HAZE T ON 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 ofle San Joaquin Local Health District. Job'A, ass, CityLl�LotSize PM Owner's Name '`�C.VG J Address ZGDi {.ef GLC &LI) hone V Contractor's Name License No. { '7 D O/%_�p Phone TYPE OF WELL/PUMP: NEW WELL X WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTA�LLATIO 1/� SYSTEM REP*IR 171 OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES O 0/ DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELD PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS �i a ❑ Industrial ❑ Open Bottom Manteca Dia. of Well Excavation Dia. of Well Casing / Domestic/Private Gravel Pack ❑ Tracy Type of Casing Specifications ( A J ❑ Public ❑ Other II ❑ Delta Depth of Grout Seal Type Grout ❑ Irrigation ---Approx.{Depth ❑ Eastern Surface Seal Installed by 1J,4Z1e&4_J Repair Work Done ❑ Type of Pump' H.P. State Work Done Well Destruction ❑ Well Diameterr Sealing Material (top 50') Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ Wo septic system permitted if public sewer is ' available within 200 feet.) installation will serve: Residence f Commercial Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: _Water-table depth SEPTIC TANK ❑ Type/MfgCapacity_ No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line I � LEACHING LINE ❑ No. & Length of lines Total length/size i' FILTER BED ❑ Distance to nearest: Well Foundation Property Line r I � SEEPAGE PITS ❑ Depth I Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I O 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 following: "I certify that in the performance of the work for which this permit is issued, I shall not 1 n 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 Cal"ornia." The appli ust call for a_II r uir inspections. C plate drawing on vers side. Signed Date: FOR DEPARTMENT USE ONLY e IIS � , Application Accepted by Date /_..? 2�+0 2 Area Pit or Grout Inspection by r ate Final Inspection by Nff4 Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3121 ❑ Manteca 823-7104 C7 Tracy 635-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 1 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT"N0. INFO {, -+ EH 13-24{REV.10!831 EH 1428. 11