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,a b APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. }HAZEL T ON AVE., STOCKTON, CA Telephone (209) 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., I Job Address / �/�D / / G��L�' (�City Cr//1�//j'�r4�lnt Size PM Owner's Name "4 /L� Address Phone IM H41'15-4:5,v^ Contractor f! / Address d icense No.y3 -J2_ Phone TYPE OF WELL/PUMP: NEW WEL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INS-��ALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE i FOUNDATION AGRICULTURE WELL : OTHER WELL PITS/SUMPS ,F - INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom .❑ MantecaDia.of.Well Excavation k Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Palck ❑ Tracy Type of Casing '4 Specifications I'I Public Cl Other1. Cl Delta Depth of Grout Seal Type of Grout _ O I I Irrigation Appro : Depth' ? I I Eastern Surface Seal Installed by _ Repair Work Clone ❑ Type of Pump H.P. State Work Done_ ii. Well Destruction ❑ Well Diametieir Sealing Material (top 50') d Depth Filler-Material (Below 50')- TYPE OF SEPTIC WORK: -NEW INSTIALLATth REPAIR/ADDITION I 1 DESTRUCTION I 1 {No septic system permitted it public sewer is available within 200 feet.) I[ Installation will serve: Residence C><_Commercial Other Number of living units: --I— Number of bedrooms Character of soil to a depth of 3 teeth C.1-14Y f Water table depth SEPTIC TANK ❑ Type/Mfg P �� Capacity a1_ y No. Compartments PKG. TREATMENT PLT. ❑ Method f 9sposal (� Distance:to nearest: Well Foundation _ Property Line 1 LEACHING LINE No. & Leingth of lines Total length/size FILTER BED ElDistanceil�to nearest: Wel Foundation Property Line 1h. SEEPAGE PITS I I igDepth 11Size Number __ f _ -216 Property Line SUMPS l !/DiFoundation Well' stance!to nearest: �_ DISPOSAL PONDS ❑ �! 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 Di§trict. 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 tali fo all require inspecti s. Complete drawing on reverse side. Signed X Title: -a Date: Date: FOR DEPARTMENT USE ONLY Application Accepted by N� Date 14yllAf Area Z Pit or Grout Inspection byDate Final Inspection by Date Additional Comments: f. ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE'.�I AMOUNT REMITTED RECEIVED BY DyyyyATE WPERM1117'�NO.+.EH 14-241REV1/951 EH/4-28 li.