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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH .PJSTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES I 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. 1851 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. t 40f_07= A�_C-eye-A Job Address City ' Lot Size �� PM Owner's Name �� G �� ✓ ✓Address Phone _ ,}+i*,G ' .. _ r — �- w m.- +as� .Tr.r.r.n.. __ w.-..-+rn•.r - _ v Contractor fg! : � U/"ap ( -Address loYl �l/. iv .r✓ License-N'o`: YSY7G Phone I TYPE OF WELL/PUMP: NEW WELL.,❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ !k PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ 1 DISTANCE TO NEAREST:,:SEPTIC TANK h 'SEWER LINES DISPOSAL FLD. PROP. LINE 4FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS ` INTENDED USE �t TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial f ❑ Open Bottom—'.,. El Manteca Dia. of Weil Excavation Dia. of Well Casing � L3 Domestic/Private El Gravel Pack ❑ Tracy Type of Casing Specifications C3 Public /t❑ Other __El.Delta. _ Depth of Grout Seal Type of Grout ❑ Irrigation `.`4' V'� %Approx. Depth ❑ Eastern Surface Seal Installed by J, Repair Work Done ❑ Type of Pump H.P. State Work Done 1� 4 Well Destruction ❑ vWellrDiameter Seating Material {top 50`1 N Depth Filler Material (Below 501 r \ STYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION ❑ (No septic system permitted if public sewer is i available within 200 feet.) lation will serve: Residence'✓ Commercial—I Other Jn.41 Number of living units: _""Number of bedrooms Wate_table depth. Character_of soil,to a depth of-3 feet: ��, SEPTIC TANK fO Type/Mfg - GX►►S7~ir'� �� — CapacityNo. Compartments r' PKG. TREATMENT PLT. ❑ x Method of Disposal f` Distance of nearest: Well Foundation Property Line_ LEACHING LINE '�No. &_Length of lines Total length/size dr9 f J FILTER BED ElDistance to nearest: Well Foundation 30 Property Line 3 " / SEEPAGE PITS Qr Depth _�S� Size � _ Number {` r - r7 Property Line^/00 tYi6UMPS ❑ Distance to nearest:" "Will J012 � Foundation DISPOSAL PONDS ❑ 4 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 certlf les 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 reverse side. Signed Title: Date: FO=EPAR MENT USE ONLY Application Accepted by Date �4--D� Area O Pit r Grout Inspection by to Final Inspection by Fate -7 L 30 Additional Comments: ' ❑ Stk 466-6781 ❑ Lodi 369-3821 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Envirorimental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 t FEE AMOUNT DUE if AMOUNT REMITTED CK RECEIVED BY DATE PERMIT"NO. INFO GASH �r.--/y. • + EH 13-241REV.5/a 5)428 �� EH 1 117CY• �p i xf