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A: + APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT NOISiA10 H11d3H 1V1N3W408JAN3 VS331A83S H1,1V3H 0nend SAN;OAQUINCouNn. 1601 E. HAZE T ON AVE., STOCKTON, CA AlW103 NlnbVOr NVS ENVIRQNMEN'!' PUBLIC HEALTH S�1e QW) 466-6781 WPIRES 1 YEAR FROM DATE ISSUED . 0661 4tlw k SPECIAL PERMIT�11 (Complete in Triplicate) ®3Ad30.3H Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work r 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 41t,San Joaquin Local Health District. Jab Address S25 W QST Et-E V ENTH s BZF-ET= city TRACV Lot Size PM p;-A-"�D �+��' SAN�,if�• s � Owner's Name Address tiU�l Phone Contractor . Address License N Phon TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ ' PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER`W i 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 ❑ El ��j7 Industrial Open Bottom ❑ Manteca Dia. of Well Excavation - pia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack Tracy Type of CasingG-�� PVC Specifications ❑ Publicterpprox. ❑ Delta Depth of Grout Seal 'W Q— t Type of Grout Tbm ' ❑ Irrigation Depth ❑ Eastern Surface Seal Installed by I Repair Work Done ❑ Type of Pump H.P. State Work Done mom M ii- vJt�S Wel! Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material {Below 501 �1 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence___ Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg CapacityNo. Compartments PKG, TREATMENT PLT. D Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size E FILTER BED ❑ Distance to nearest: Well Foundation Property Line E SEEPAGE PITS ❑ Depth Size i Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS Cl II 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." The applicant must call for all re wired inspections. Complete drawing on reverse side. s:• Signed Title: `Date: 71`90 _ R DEENT USE ONLY Application Accepted by Date 3—/ZX 6" 5/ 3� Pit or Grout Inspection by Date �s�G 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 CIC RECEIVED BY DATE PERMITNO. INFO CASH + EH14-241REv.t/651 �� Q /�� FH 14-26