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SAN JOAQUIN LOCAL HEALTH DISTRICT APPLICATION FOR PERMIT ENVIRONMENTAL HEALTH DIVISION SAN JOAQUIN LOCAL HEALTH DISTRICT SPECIAL. Pi RMUT 1601 E. HAZELTON AVE., STOCKTON, CA PAYMENT Telephone (209) 466-6781 RECEIVED PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ! (Complete in Triplicate) SEP 12 19$$ Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install t "erd. This application is. made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and t e u +*AteMn Joaquin Local Health District. RMCES Job Address City ��CL �t'Lot Size PM rl Owner's Name �iy��y�I'r�� oQ Address / 7A1 //'fes Cr/�� PhoneC Contractor _Al i��Address � '� License No. ✓` ?977 Phone W3 d� TYPE OF WELL/PUMP: NEW WELL` WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ;k- SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK Z.1^ ! SEWER LINES I—,r_ DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIE T NS .011'Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private e-f!7 Gravel�P�ack El Tracy Type of Casing Specifications FI Public ef�f Othe��(OA;21)- ❑ Delta Depth of Grout Seal d Type of Grout I I Irrigation _.-Approx. Depth l I Eastern Surface Seal Installed by Repair Work Done D Type of Pump S1/4#2_ H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 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 Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size Z FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size _ Number SUMPS Ll Distance to nearest: Well Foundation Property Line 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 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 for r uire ctions. Complete drawing on rev se side. Signed X Title: 1A/�t/i', Date: FOR DEPARTMENT USE ONLY Qty 7� Application Accepted by Date ^" 0 Area Pit or Grout Inspection by r/ Date Final Inspection by--) �p�,j /� Date�o�/��r' d I Additional Comments: -9 C /4/L f C11�7 E/y ❑ 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 INFO AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. +.EH13-24(REV.1i85) EH 14-26