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i APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA 1 Telephone (209) 466-6781 PERMIT EXPIRES 7'YEAR FROM DATE ISSUED (Complete in Triplicate) Application is he{eby made to the San Joaquin Local Health District for a permit to construct and`lor 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. 4 •. p / � a qac Cerra� leo t,(��w �C.1 cit T�,�c Job Address — y Lot Size PM ala- ; 3Yo0 I Owner's Name Ge&r-764 Gr -vol, OwTA afG�(d ddress �58�® diTU7A, P' /�'r�.ya r Phone Contractor LE'�l�NT�S09/ �( 7nN s Address 4W W41 410, H05& L License No. � `�✓ Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ I PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. 1 PROP. LINE 0 FOUNDATION AGRICULTURE WELL: _ OTHER WELL ` PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRICTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private { ❑ Gravel Pack ❑ Tracy Type of Casing Specifications i`l Public ❑ Other n Delta Depth of Grout Seal Type of Grout _v I I Irrigation --Approx. Depth l I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H:P: - State Work Done _ Well Destruction ❑ Well Diameter Sealing Material {top 50'i O # Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION 1 l REPAIR/ADDITION [I OESTRUC7 ON I (N septic system permitted if public sewer is r a ilable 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 IV Type/Mfg &e ceq5l' Cdr, Capacity J/ROO No. Compartments 7+ PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation- 10 Property Line + ` LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: ...,..--Well Foundation Property Line SEEPAGE PITS 1 1 Depth Size _ Number # SUMPS ❑ Distance to nearest: WelF T Foundation Property Line DISPOSAL PONDS ❑ e\ - 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 i 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 rwsl call for all required inspections. Complete drawing on reverse side. Signed X Title: Date: DR DEPARTMENT USE ONLY f` Application Accepted by Date Area i Pit or Grout Inspection by Date Final Inspection by to �l i i Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 j Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Silk., CA 95201 FEE i INFO AMOUNT DUE A OU[N�T REMITTED CCK RECEIVED BY DATE //''PERMIT-NO. +,EH13-24{REV.]/mW S 64-� l �` ' '�/' �� Cw`� YJ„_ EH 14-26 .••VVVV / ��IIJ�w lC 66