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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES l'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 Reguiations.of the San Joaquin stocal Health District. d � �© !V ff G��L OCC �'I1/ �DG>.t � PM k,.,�:. - :.,,RJob Address City Lot Size Owner's Name fI'1 / e / Address17,3 �j1 Ger S'e Phone y" --TT- � r f Contractof,7.L. GRASS San Address St{d7 S e- pf^ License No. JAd ly Phone 7Ys 2727 TYPE OF WELL/PUMP: NEW WELL / WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION lid SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK 701. SEWER LINES " DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE T PE OF WELL PR08LEM AREA CONSTRUCTION SPECIFICATIONS 0 Industrial #- Open Bottom -❑ Manteca - _ Dia. of Well Excavation Dia. of Well Casing r. � 0bomestic/Private ❑ Gravel Pack C1 Tracy Type of Casing _S IAC , y Specifications i l'1 Public ¢ 1-1 Other F1 Delta Depth of Grout Seal -0 Type of Grout " I i Irrigation 4799_�Approx. Depth I I Eastern ''llSurfaceaal Installed by 3 _ Repair Work Done ❑ Type of Pump �t> H.P. Pa- if State Work Done _ t Wel! Destruction ❑ Well Diameter Sealing Material (top 50') ' Depth Filler Material (Below 50') ` TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 Rl E-PIR/ADDITION I t DESTRUCTION I I (No septic system permitted if public sewer is Q available within 200 feet.) ) Installation wills Residence_ Commercial_ Other _ ,R Number of living units: umber of bedrooms Character of soil to a depth of 3 feet: r ale depth Y c SEPTIC TANK Cl Type/Mfg Capacity No. Compartments' PKG. TREATMENT PLT. ❑ Method of Disposal .� ry } Distance to nearest: � Wel! Foun Property Line 1 LEACHING LINE ❑ No. & Le o linest'' ) Total leng e FILTER BED E ❑ ante to nearest: #Well ,r.a Foundation Property Line / j e SEEPAGE Pl I I Depth Size ! Number l SUMP C1 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ ' I hereby certify that I have prepared this application and that the work will Ife done in accordance with San Joaquin county ordinances, state laws, and s rules and regulations of the San Joaquin Local Health District. 1 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." t F J The applicant must ca for all required inspect ns. Complete drawing on reverse side. • Cy Signed X Titre: A�� ✓�" _ r Date: a FOR DEPARTMENT USE ONLY � Application Accepted by LLI DateArea 1 �a•� we-L� c.��s d�_fl y Pit or Grout Inspection by O<;e Final Inspection by no a Date Additional Comments: 4 ❑ Stk 466-6781— ❑ Lodi 369-3621 ❑ Manteca '823-71 ❑ Tracy 835-638 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT-NO. INFO F1 a.EH13-21(REV. /H5) kx EH 14-26