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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1641 E. HAZEL T ON AVE., STOCKTON, CA i,1_ v L. `? Telephone (209) 466-6781 SEP 13 14''n0 PERMIT EXPIRES 1'YEAR FROM DATE ISSUE INVIRONMENTAL (Complete in Triplicate) PERW11T/SERVi(CES 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 `___. City Lot Size PM Owner's Name � Address Phone Contractor f_Address -ten License No.4396 2- Phone 25:5 2Z$l TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION Uk SYSTEM REPAIR OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA 'CONSTRUCTION SPECIFICATIONS ❑ Industrial D Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing YQomestic/Private ❑ Gravel Pack ❑ Tracy - ` ' Type Casing Specifications 1-1 Public 171 Other ❑ Delta Depth-of Grout Seal Type of Grout__, I I Irrigation Approx. Depth I 1 Easternurface Seal installed by _ Repair Work Done �Kl Type of PumpH.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material Itop 50) Depth Filler Material (Below 501 Com, TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIRlADDITION l I DESTRUCTION i I (No septic system permitted it public sewer is t� available within 200 feet.) l r Installation will-serve:- Residence— Commercial— Other Number of living units: Number of bedroomsQ Character of soil to a depth of 3 feet: Water table depth I SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ '" 'x a 4 Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I i Depth _ '' -Size- Number SUMPS Ll Distance to nearest: Well `Foundation Property Line 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 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 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." Theapplicant st ca r II required i spections. Complete drawing on reverse side. p Signed X �i.� Title: Date: �7—7— !o R DEP'A"`11111/R'''"'TMENT USE ONLY Application Accepted by Date Area } Pit or Grout Inspection by Date Final Inspection by Date ,? -,P19,3 1 Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. +.EH 13-24 IR EV.vn51 �� `� EH 14-26