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APPLICATION FOR PERMIT 'R Ek";- E SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA ASR 9 19120 Telephone (209) 466-6781 ENVIRONMENTAL HEALTH PERMIT EXPIRES 1 YEAR FROM DATE ISSUED PERMIT/SERVICES (Complete in Triplicate) '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 /23 ,S s - City,�G4LlIrl/ Lot Size PM Owner's Name lq4UL &1W2 Address Phone i Contractor_ dressZTXZXLense No Phone TYPE OF WELL/PUMP: NEW WELL WELL REPIfACEMENT C] DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION' AGRI6U TORE GV [JTHER W- EL1�7 y�"""PITS-/SUMPS � O INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICAT ONS ;❑ industrial ❑ Open Bottom` T F)-Manteca- Dia:.of Well Excavation 2 Dia. of Well Casing Domestic/Private `Gravel Pack ❑ TracyType of Casing Specifications 1-1 Public ❑ O her ❑ Delta ' Depth of Grout Seal PType of Grout I I Irrigation /tr_e pprox. Depth `4_Eastern Surface Seal Installed b f Repair Work Done ❑ Type of Pump H.P. State Work,Done_ Well Destruction ❑ Well Diameter ~\Sealing Material (top 501 Depth `%4 Filler Material (Below 501" TYPE OF SEPTIC WORK: NEW INSTALLATION I1 REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is �---- Y available within 200 feet,) Installation will serve: Residence— Commercial"_ Other N 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. ❑ 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 r SEEPAGE PITS ( 1 Depth Size _ Number r —SUMPS- -Well -. .—Foundations-^---'— _Pro e 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 Diktrict. 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 c ify 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 Californi ' r The app/' t, us li all re "ed inspections. Complete drawing on r A�sidia. Signed X Title: Date: _IeX DEPARTMENT USE ONLY Application Accepted by Date__ �D / _ Area Pit Lou Inspection by Date �5� final Inspection by Date Additional Comments: 7 ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-71 CI Tracy 835-638 Applica t - Return all opie to: Environmenta ealth Permit Se ices 1601 E. HazeltonAve., P.O. Box 2009, Stk., CA 95201 �� 4��F��2c�iF�� c/rr�wFt�a..a�6�L, �,� FEE INFO AMOUNT DUE AMOUNT REMITTED CK 4 CASH RECEIVED BY DATE PERMIT'NO. + EH 13-24 REV.tin51 ll�. EH 14-28 ` 10 Af4Q 5 t