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APPLICATION FOR PERMIT RECEIVED SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA JUN 2 2 19M Teleptlorie (209) 466-67$1 ENVIRONMENTAL HEALTH PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) PERMIT/SERVICES 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 ! �—� CW ' �! iJ �•�- `-e''" City Lot Size PM CCi V J''dLL Owner's Name Address � �� Phone F r� Contractor s` Addressl /6_��* 2 � License No. 3 g�"�` Phone � f TYPE OF WELL/PUMP: NEW WELL ❑ 'WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION D�,_ SYSTEM REPAIR OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. 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 $,,Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications r Public 1-1 Other Cl Delta Depth of Grout Seal Type of Grout I I Irrigation _Approx.'D pth.— 1.1 EasternSurface Seal Installed by Reo _ air Work Done � Type of Pum ` Repair yp p ,�..��=,-:.� H:P.- ��. State Work Done Well Destruction 0 Well Diameter Sealing Material (top 50') --- Depth Filler Material (Below 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I i INo septic system permitted if public sewer is V1 available within 200 feet.) a Installation will serve: Residence I Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet:t Water table depth SEPTIC TANK ❑ T ype/{Ulfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation"-4 Property Line w LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance t+ nearest: Well Foundation Property Line SEEPAGE PITS i I Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I 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 in4he performanFe of the work for which this permit is issued, I shall not employ any person in such manner as to ibecome 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,l shall employ persons subject to workman's compensa- tion laws of California." i The applicant mu f r all requir6d ins ns. Complete drawing on reverse side. / ll Signed X - 'Title: Date: fO" u ORbEPARTMENT USE ONLY Application Accepted by y " ' Date Area S Pit or Grout Inspection by ate Final Inspection by Date �7 v Additional Comments: r ❑ 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 1 FEE INFO AMOUNT DUE AMOUNT REMITTED GASH RECEIVED BY CK f DATE PERMIT No. ♦.EH13-24IREV.1/A 5) EH 14-28 _ .�•`f• �! Q y�