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r APPLICATION FOR PERMITy �� --� SAN JOAQUIN LOCAL HEALTH DISTRIC 1601 E. HAZEL T ON AVE., STOCKTON, CA . Telephone (209) 466-67$1 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 11�} i (Complete in Triplicate) ENVpIFROMIE/NTAL HEALTH Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herei�i�escr'i�ed. his appl 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 bistrict. f i 2_ S A G S -Z—:1) `/ o Job AddressCity r 0 r©"N Lot Size 19c,, y�/� "� � PM Owner's !Name �'f -IV Address � C �►/Wrti J� Phone Contractor f C) , sJ yC if Q' [f3D ,( }}-- ry 7.2 Address License No. ! �(/ phone, TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ ` t 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 ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 1-1 Domestic/Private C1 Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 50'1 n TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION ❑ IN.septic system permitted if public sewer is V q available within 200 feet.] _n Installation will serve: Resdence Commercial.— Other �J Number of living units: Number of bedrooms (1 Character of soil to a depth of 3 feet: -r►._ Water table depth V�l SEPTIC TANK ❑ Type/Mfg 1C� ° ala Ca act �� tY__Z_2 Z No- Compartments PKG. TREATMENT PLT..❑ f Method of Disposal Distance to nearest: Well �Q Foundation – 3 M Property Line�� LEACHING LINE X No. & Length of lines — IT 'LTot� length/size Q FILTER BED ElDistance to nearest: Well D Foundationproperty Line�� f SEEPAGE PITS ❑ Depth Size Number SUMPS Distance to nearest: Well 1 �� Foundation �� - Property Line DISPOSAL PONDS ❑ 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. k 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." Contractors 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 o California." The applic st call for all required inspections. Complete drawing on reverse side. Signed Title: Date: % d ( FOR DEPARTMENT USE ONLY ; Application Accepted b pP P Y �`� �fr,x 17 +� � l Date o— 1 Area Pit or Grout Inspection by Date , Final Inspection by Date ._:.! 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 AMOUNT DUE AMOUNT REMITTED INFO CASH RECEIVED BY DATE jPERMIT-NO.. EH 13-24(REV.I/N slEH 14-2a 9'lp'^'� 7