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Ira f r 9� , APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1'AYN► HT. 1601 E. HAZEL i ON AVE., STOCKTON, CA R ECEI VED Telephone (209) 466-6781 MAY Z PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) NVIRONMFNT L Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the worla �f cation is made in compliance with San Joahquin County Ordinance No. 549 for sewage or No. 1662 for well/pump and the Rules and Re i P �f1e San Joaquin Local Health District. ec-47rt Oac CISNTYrZ Cptit]�� (3LD,E, Na• ZO-33S'ro� GBTwNE AC,4 ein- Co. POPLM) Job Address , jtre4g— City Lot Lot Size PM ; Owner's Name Gde'�I El, N Address � ss � Phone 7 600 Contractor ress 2 � Er PnY/ZP't46 �F; License No.s:: Phone 9y8 13�1f TYPE OF WELL/PUMP: !� NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER -! DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. ROP. LINE .�� r If FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS D/ ¢ INTENDED USE TYPE OF WELL PROBLFMAREA CONSTRUCTION SPECIFICATIONS ,�� (dyV FNJ LlIndustrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation LlDomestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing -6peeificetiovis�7G�1C7 / i i 5 1-1 Public F1 Other F1 Delta Depth of Grout Seal +5eest�— T/v/_ I I Irrigation Approx. Depth l I Eastern Surface Seal installed by _ Repair Work Done ❑ Type,!f Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth? Filler Material (Below 501 TYPE OF SEPTIC WORK: NEWI INSTALLATION I7 REPAIR/ADDITION l I DESTRUCTION I i INo septic system permitted if public sewer is available within 200 feetA 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. ❑ i� Method of Disposal Distance to nearest: Well Foundation Property Line IM LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line i A SEEPAGE PITS I I Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that I have pteparred this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and ` rules and regulations of the SanCJoaquin Local Health District. 1 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 t certifies the following: I certify that in the performance of the work for which this permit is issued, I shall employ { " y pe p p y pers6ns subject to workman's compensa- tion laws of California." I1 i ; The applicant st all for all uired inspections. Complete drawing on reverse side. 1 � I Signed X iz Title: 4 S Date: I FO DEPARTMENT USE ONLY I, / p Application Accepted by Date r d Area .2/ 1 A Pit or Grout Inspection by II Date Final Inspection b Date I Additional Comments: i� ❑ Sik 466-6781 ❑ Lodi 1369-3621 ❑ Manteca 623-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601"E. Hazelton Ave., P.O. Box 2009, Stk., CA 85201 I� I FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT'NO. INFO CwsH ♦ EH 13-24(REV.I/H51 EH 14-26 Il. 1 SAL,19" �1Z i