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' APPLICATION FOR PERMIT RECEIVED SAN JOAQUIN LOCAL HEALTH DISTRICT JUN 7 �g� 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 ENVIRONMENTAL HEALTH PERMIT EXPIRES 1 YEAR FROM DATE ISSUED PERMIT/SERVICES $ (Complete in Triplidate) 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 I 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. -y Job Address - _ LQts / 2 City��N-- Lot Size w0AC�i PM Owner's Name L�F �Tf�hi4- Address 1I` Phon - Contractors-jN� tddress S e� License No Phone - TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION El PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER © /f DISTANCE4TO NEAREST: SEPTIC,TANK . 10I2C1 SEWER LINES._ DISPOSAL FLD.t2a PROP. LINE _Z0_LIT- x FOUNDATION 6(21-'77AGRICULTURE WELL -- OTHER WELL PITSISUMPS h INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Lle, k 11Industrial ElOpen Bottom ❑ Manteca Dia. of Well Excavation i Dia. of Well Casing V-Domestic/Private ';.Gravel Pack ❑ Tracy Type of Casing-&C, S Specifications i FI Public n Other//p,.—f Ci Delta Depth of Grout 4e1al'Q 06 Type of Grout 11'Irrigation pproK. Depth Y�Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done ° Well Destruction ❑ Well Diameter Sealing Material Itop 501 Depth Filler Material IBelow 50'1 -- TYPE OF SEPTIC WORK: NEW INSTALLATION I:1 REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is --availablewithin-200-feet-)---'-- 1 Installation will serve: Residence_ Commercial_ Other- Number of living un Number of bedrooms Character of soil to depth of 3'feet-- Water table depth 't No. Compartments SEPTIC TANK:, ❑ Type/Mfg Capacity .r PKG. TREATMENT'PLT,..[D Method of Disposal i 'Distanc'e-'to nearest: Well Foundation Property Line LHuvG LINE ❑�No. Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS { I Depth Size _ Number SUMPS- ❑ Distance to nearest: Well r Foundation `; Property Line—" Found. DISPOSAL PONDS ❑ I hereby certify that t 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, l 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 cert if 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 Calif rnia." The appllaws a u c or requir spec ions. Complete drawing on r e e Side. �----- Signed X Title: AawDate: FO EPA ENT USE O Application Accepted by Date Area Pit o Grout speciion byp Date Final Inspection by ;Date Additional Comments: ds� �/fs��i,�iP�✓c��,��" % o C Stk 466-6781 0 Lodi 369-3621 0 Manteca 823-7TNI ❑ Tracy 5-6385 1/0 xo.,' oreee"4z f Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Sik-, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. INFO F _ + EH 13-24(REV.t i n 5) © '7 EH 14-26