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APPLICATION-FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA r Telephone {2091 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 ,I�'G 7 ,4t�f Cd 100 Lc/ City •S Y G'CK Lot"Size 7_G'4 fid,U _ PM Owner's Name f'. G'. Z Z Address _ P"hona, Contractor's Name License No. Z4"Y`•74-3 Phone V&to ?6 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT C7 DESTRUCTION ❑ " PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑. DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE J FOUNDATION AGRICULTURE WELL OTHER WELL PITS/STUMPS L INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 4 I] Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ 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 r"❑ Well Diameter Sealing Material {top 501 �Q Depth Filler Material Welow 501 9 TYPE OF SEPTIC WORK: NEW,INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION No septic system permitted if public sewer is Q available within 200 feet.) O 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. ❑ Method of Disposal Distance to nearest: Well' Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property.Line SEEPAGE PITS ❑ Depth Size Number SUMPS Cl 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 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 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. Complete drawing on revers ' e. Signed Title: Date: FOR DE ARTMENT USE ONLY DU Application Accepted by `j D —` / Area J Pit or Grout Inspection by Date Final Ins tion by Date d tonal Comments: Stk 466-6781 ❑ Lodi 389-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Boic 20W, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED ICASH RECEIVED BY DATE PERMIT"NO. + EH 13-24{REV.191831 EH 14.28 '�� "��•-�•