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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON 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. Job Address City��iEi—f �12'ot Size CSV M ter•- A 1 � r Owner's Name ��C ®Address e/� GGC �LC/f/ Phone �S7/ 174 ?� Contractor's Nam License No. Phone / TYPE OF WELL/PUMP: NEW WELL ii1 , WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION 9-� SYSTEM'REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK L"'r%EWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS _ ❑ Industrial ZI-O 1 Bottom ❑ Manteca Dia. of Well Excavation 47 ' ( Dia. of Well Casing 8-B mestic/Private El Gravel Pack ❑ Tracy Type of Casing z/�9. pecifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal T pe t ❑ Irrigation ---Approx. Depth ❑ stern Surface Seal Installed by Repair Work Done ❑ Type of Pump }r 2 H. P, 5 State Work Done Well Destruction ❑ Well Diameter Sealing Material stop 50'1 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No 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 LEACHING, ' LINE E]No.' & Length of lines Total length/size FILTER BE °: ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL" PONDS ❑ r neraoy cermy that r nave 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 cekifles 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." f 'The applicar� rn all f II required inspections. Complet r wing on reverse side. r i Signed - ��>/_�./A A ` Title: _ �[ Date: _ g r FOR DEPARTMENT USE ONLY Application Accepted by Date V�✓ Area __ I f � Pit or rou Inspection by Date c�V Feon by _ �C�uIC' inal InspctiDate Additional Comments: ❑ 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 + EH 13.24 MEV. 101831 EH 1126 FEE INFO AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT"NO, i to f31��+� 8 4-1Bg3 N