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APPLICATION-FOR PERMIT f. SAN JOAQUIN LOCAL HEALTH DISTRICT jj 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) t 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 4,0 GQ D pi Gngz�mck.Y\ Q,LJ City e PM Owner's NameIhn � Address 6CAViq-� Phone Contractor f4LwL( Address License N">-9 —Phone qtAly-N 2-C TYPE OF WELL/PUMP: NEW WELL ❑ WELL 9EPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR,K OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS I INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing { ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications f-1 Public ❑ Other n Delta Depth of Grout Seal Type of Grout I I Irrigation —..Approx. D pth I Eastern Surface Seal installed by _ Repair Work Done ❑ Type of Pump tUf b( H.P. 10 State Work Done �U Well Destruction ❑ Well Diameter 1y �f Sealing Materia! /top 501 Depth Filler Material (Below 501 _ TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I iNo septic system permitted if public sewer is available within 200 feet.) 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 1 LEACHING LINE ❑ No. & Length of lines Total length/size # FILTER BED ❑ Distance to nearest: Well Foundation Property Line f SEEPAGE PITS I I 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 + rales and regulations of the San Joaquin Local Health District. Home owner br 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." i The applicant st cal wired in spe tions. Complete drawing on reverse side. 11 II I Signed X Title: Date: FOR DEPARTMENT USE ONLY AppiicationllAcce d by Date —'6 Area Pit or Grout inspection by Date Final Inspection by Date S"124641 Additionai mments: ❑ Stk 46626781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - �aturn all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Silk., CA 95201CK ig FEE / INFO AMOUNT DUE AMOUNT REMITTED ASH RECEIVED BY DATE PERMIT'NO. �y h /} ,y/^/�� IE +.EH 14.21 1REV.n a si 11CU � � 4 1- �� U / EH t1-2a �"-/ !l 1&ci-109