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Z4 a APPLICATION FOR PERMIT, [N SAN JOAQUIN LOCAL HEALTHEl DITRICT I 1601 E. HAZEL T ON AVE., STOCKTON, CA AUG 3 1 1%220 Telephone (209) 466-6781 ENVIRONMENTAL HEALTH PERMIT EALiH PERMIT EXPIRES 1 YEAR FROM DATE ISSUED FERMI It T%; f7,,'i'C):: ' ! (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 - '1 '9I1P1� i^} o� _ City Lot Size pM Owner's Name Address Phone Contractor dJ -: Address 6S65a�— n License No.�_Phone TYPE OF WELLlPUMP: it NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR P< OTHER ❑ DISTANCE TO NEAREST: SEPj IC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Domestic/Private ❑ Giavel Pack ❑ Tracy Type of Casing Specifications y� - i'l Public D O��er ❑ Delta Depth of Grout Seal Type of Grout V i I ! Irrigation � pprox. Depth I I Eastern Surface Seal Installed by Repair Work Done Type'of Pump H.P. State Work Done Dh ..+ Well Destruction ❑ WeII,Diameter Sealing Material flop 50'1 � DeptAl: Filler Material (Below 60') TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I } ifVo septic system permitted if public sewer is T available within 200 feet.} Installation will serve: Reside)ce_ Commercial_ Other Number of living units: 1 Number of bedrooms Character of soil to a depth of;3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKC:.TREATMENT PLT. 1-1Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No & Length:.wof lines Total length/size FILTER BED LiDistance-triea�es't : Well Foundation Property Line All, ` q SEEPAGE PITS i I Depth Size ' Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS_. �[9 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 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 fallowing: "I certify that in the performance of the work for which this permit is issued, tion laws of California." I shall employ persons subject to workman's compensa The applicant must call for all regluired inspections. Complete drawing on reverse side. Signed X Title: Date: ' �II L 1pY1OR DEPARTMENT USE ONLY Application Accepted by I11 Date tJ Area Pit or Grout Inspection by._ hA Date Final Inspection by Date Additional Comments: �I' ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 635-6385 Applicant - Return all copies to: EII� A 95201nvironmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 20(x9, Stk., C + FEE AMOUNT'bUE AMOUNT REMITTEDCK INFO Ir CASH RECEIVED BY DATE PERMIT'NO. - ♦.EH13-24(REV.1in51 EH 14-26 I t _