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PAD i n vitt �=. laW APPLICATION FOR PERMIT AVAV SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA p er V>ED 43, U–U Telephone (209) 466-6781 Vt SAN JOAQUIN LOCAL. HEALTH E009 EXPIRES 1 YEAR FROM DATE ISSUED ENVIRONMENTAL HEALTH Diviz (Complete in Triplicate) SPECIAL PERMITOA N'�P Application is eieby made to the San Joaquin Local Health District for a permit to construct and/or install the wor ,I- s application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and thF �Rj �fe San Joaquin Local Health District.. Q QE Job Address T r ' ?, Cha Y"tom City Lot Size— PAY-16 PM Owner's Name Ci � ��1Y1�%- 0 Address ��Y' l1��_l(��. �14 Phone Contractor i Tl�r�f'is,fY1 Address �AQ1f" e--0 '`kcense No.LA Phone TYPE OF WELL/PUMP: NE ELL JK WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ 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 SPECIFICATIONS11 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation R1 `` Dia. of Well Casing Domestic/Private Gravel Pack ❑ Tracy' Type of CasinghE. i%, �h VC- Specifications FI Public F1 Other F1 Delta Depth of Grout Seal Type of Grout I I Irrigation �.Approx..Depth I I Eastern Surface Seal Installed by k— V6 ° Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter 11 Sealing Material (top 501 A Depth ckV Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I l REPAIR/ADDITION l I DESTRUCTION I I (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 Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal tl Distance to nearest: Well Foundation Property Line _ LEACHING LINE Cl 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 \w 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 DiMrict. Home owner or licensed agent's signature certifies the following: "1 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, 9 INnt(DMtW'E91lUI,Fj'EM'1NY�I F tion laws of California." ENVIRONMENTAL HEALTH DIVISION The applicant nNst call for all required inspe _ions. Complete drawing on reverse side. SPECIAL r Signed X Title: �� ' G' � t �7 Date: lam\ FOR DEPARTMENT USE ONLY Application Accepted by `!} Date Area Pit or Grout Inspection by ZDate 1/Z 1" Final Inspection 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 CK 0 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT'NO. INFO CASH ?0-66 �G�• Hca �, r�� 47 +.EH 13.24(REV.i i x s) EH 14-2a