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} APPLICATION FOR PERMIT ! f SAN JOAQUIN LOCAL HEALTH DISTRICT RECEIVED 1601 E. HAZELTON AVE., STOCKTON, CA JUN �'4 ' E Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ENVIRONMENTAL HEALTH (Complete in Triplicate) PERMIT/SERVICES f Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work hereindescrib I�d. 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. //�/�,,J/� /,/f�� Job Address -1 v+"i�vf, f/{/l'u�i f Lot Size PM I� O ner's Name ss 9 /i Phone I Con rac o- t r._ , r $s J �� Lic nse No. PhoneM �� c7 Q TYPE OF WELL/PUMP: NEW WELL ID WELL REPLACEME E] ❑ DESTRUCTION PUMP INSTALLATION SYSTEM REPAIR ❑ MOTHER ElDISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. i PROP. LINE: FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USEv TYPE OF WELL PROBLEM ARFA CONSTRUCTION SPECIFICATIONS, ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing �omestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing i Specifications � . f)'f ublic f7 Other I. : C7 Delta Depth of Grout Seal Type of Grout _ I I Irri�a'lmn _Approx. De th I t Eastern i ace Seal Installed by Repair Work Done ❑ Type of Pum H.p, State Work Don f ,. .` Well DesicuctionY ❑ Well Diamet�� Sealing Material (top 50') / Depth_ Filler Material (Below 50') TYPE OF SEPTIG.,WORK: NEW INSTALLATION I I REPAIR/ADDITION i I DESTRUCTION I I INo septic system permitted if public sewer is ## available %Whin 200 feet.) Installation will sem: residence�• Comm rcial Other i tom, .., Number of living units: Numberybf bedrooms � ��4 I I �,. Character of soil to a depth of 3 feet: i �� ti:3 ' Watrruble depth i SEPTIC TANK ❑ Type/Mfg I Capacity I No.!Compartments PKG. TREATMENT PLT. ❑ 4 i m (� McLd of<Disposal Distarie'to`t5e #est' 1ell FoufRfetion rorty L-tni LEACHING LINE ❑ No. & Length of lines Total length/size r 1M FILTER BED ❑ Distance to nearest: Well Foundation ` Property Line SEEPAGE PITS I I Depth Size _ Number _ I� SUMPS ❑ Distance to nearest: Well Foundation Property DISPOSAL PONDS ❑ P rty the I , I hereby certify that I have prepared this application and that the work will be done in accordance with San Jo aquin-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 workfor hick this permit ils issued, 1 shall not employ any person in such manner as to become subject to workman's compensation laws of California."Contracfor's hiring or sub co`nuacting signature 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 I� f The appfican W call r all .red inspgctions. Complete drawing�revee. f Sig ed Titl p Date: F R EPARTMENT USE ONLY Application Accepted by . 1 Date '� G Area ' Pit or Grout Inspection byDI ate Final Inspection by late Additional Comments: I� I ❑ Stk 466-6781 ❑ Lodi 369.3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 ! f Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009,1 Stk., CA 95201 t 1 FEEAMOUNTDUE AMOUNT REMITTED CK INFO CASH RECEIVED BY DATE PERMIT'N10. +.EH 13-24(REV.I/AS) `�� N EH -28 L/ - l� t