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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT JAN I '98,�0 1601'E. HAZELTON AVE., STOCKTON, CA E Telephone (209) 466-6781 ENVIROMENTAL HEALTH PERMIT EXPIRES 1 YEAR FROM DATE ISSUED PERMIT/SERVICES . (Complete in Triplicate) w - 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 Sam Joaquin Local Health District. R n ON RNJ 2--3,`-Y7 _ I Job Address - ` AdCity Lot Size PM dress p j {I Owner's Name c'(O /l L �6ne Contractor" Address Jl License No. d �3 Phone / O t TYPE OF WELL/PUMP: NEW WELL; WELL REPLACEMENT ❑ DESTRUCTION ❑ I t PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK r)b"he SEWER LINES DISPOSAL FLD. nnhPROP. LINE FOUNDATION w AGRICULTURE WELL OTHER WELL PITS/SUMPS-' INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industria! C1 Open Bottom ❑ Manteca bio. of Well Excavation f Dia. of Well Casing ❑ Domestic/Private )(Gravel Pack ❑ Tracy Type of Casing Specifications EE ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout I irrigation 9 --Approx. Depth El Eastern Surface Seal installed by • --� � Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501) Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is • I. available within 200 feet.) Installation will serve:—Residence Commercial�. Other - Number of livirig 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. El " a Method of Disposal i Distance to nearest: Well Foundation Property Line LEACHING LINE ' e ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line . a SEEPAGE PITS I �, ❑ Depth Size a Number - SUMPS - " ❑ Distance to nearest: Well's°"- - Foundation � s =Property-L-ine---- DISPOSAL PONDS ; ❑ 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 k rues 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 contra ed, signature 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- certifies tion laws of California." - The app-can must call for all re ad inspect! ns. Complete drawing s' e. Signed Title: �j Date: 1--ey- Q 7 FOR b€PA ENT USE ONLY Application Accepted by Date "^/ qre i Pit or Grout Inspection by Date Final Inspection by Datel'T� Additional Comments:; ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835&385 , Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95261 i - i FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY INFO CASH DATE PERMIT NO. + EH 13-241REV.1/aril ' 7� a, EH 14-28 iv Imo/ _7/ I � t