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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 + k PERMIT EXPIRES 1 YEAR FROM DATE ISSUED „ y. (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 welt/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address Z � ��✓ G L./4"l�� City Z ___' Lot Size=1 � >� PM r - Owner's Name C_ Address Phone It GS \ Contractor's Name D Grp License No. ` �' � _ Phone �z-c-3 9,7 TYPE=OF:WELWPUMP i--NEW WELL ❑ i 'WELL,REPLACEMENT DESTRUCTION ❑ PUMP INSTALLATION.❑'' SYSTEM REPAIR Eli OTHER EJ ri i 4 DISTANCE TO NEAREST: SEPTICrTANK " SEWER.LINES DISPOSAL FLO. PROP. LINE FOUNDATION {AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL'-'.. . PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑Open Bottom ..❑ Marteca t-----Dia. of Well Excavation Dia. of Well Casing 19 Domestic/Private ❑ Gravel Pack ❑Tracy '; i Type of Casing Specifications ❑ Public 14� �. ❑ Other ❑ Delta f f Depth of'Grout Seal i Type of Grout D Ilr6gation- _ .4-1—Approx. ,} Approx. Depth- ❑ Eastern •E—I Surface Seal Installed by Repair Work Done"`-Q'___Type of Pump H.P. 1 s State`Work Done Well Destruction ❑ Well Diameter Sealing'Material {top 50'1 - Depth Filler Material {Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION 2r DESTRUCTION ❑ (No septic system permitted if public sewer is + available within 200 feet.) Installation will serve: Residence ,---,; Commerciale; Other: Number of living units: Number of bedrooms, L Character of soil to a depth of 3 feet: C i � '—" '� "' Water table depth SEPTIC TANK f�Type/Mfg'-1'6 Capacity 1 vp No. Compartments ' PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: V11e'll* C!�fa Foundation ! `A .Property Line LEACHING LINE Y - :YNo. & Length.of. Total.length/siza`•� FILTER BED LJ_ Distance to nearest Well 'Foundation 5% *>- Property Line SEEPAGE PITS Depth �� Size % Number i l - -0 SUMPS ❑ Distance to nearest: Well - Foundation PProper y,Line DISPOSAL PONDS ❑ hereby certify that I have prepared this application and that'the work will be done in accordance with Sari 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 follownng: "I certify tFfit-iffi e,peddrmance 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 compensation-laws of California."Contractor's hiring or.sub-contracting signature certifies the following:"I certify that in the performance of the work forwFiicF1 tfiis:permit is iisued;.Isfi_all employ persons subject to workman's compensa- tion laws of California." I The applicant must call for all required inspections. Complete drawing on reverse side. Signed X �.�A �'z't Title: Pate: FOR DEPARTMENT USE ONLY Application Accepted by Date` ' x ;2 _S Pit or Grout Inspection by Z Dated, Final Inspection by 2V - Date f r Additional Comments: } ❑ Stk 466-Ml ❑ Lodi -3621 ❑ Manteca 823 04 ❑ Tracy 835-6385 r Applicant- Return all copies to: Environ ental Health P rmit/Se ices 1 1 E. Hazelton �Ave y,,P.O. B x , S CA FEE AMOU T DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT"N0. INFO //��. + EH 13-241REV. "[J EH 14-26