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t3' - '`' APPLICATION FOR PERMIT SAN JOAO.UIN LOCAL HEALTH DISTRICT Nt7 1�rZ 1601 E. HAZELTON AVE.,-STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (complete in Triplicate) ,�0\.,R Vk. L"we�td OLD %+(;fit l'�s AApplication is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work heres ibed. 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 City/ LJ�1✓ City Lot Size PM s Owner's Name _ � I� tnnz. .�•� Address /Q Phon53 7' ContractorZ94 Address G� si License fVo � �P n� xpv # TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ 1 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES _ .DISPOSAL RLD. PROP. LINE lv j 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 i ❑ Domestic/Private ❑ Gravel Pack .--._.❑ Tracy, Type of Casing Specifications i ❑ Public ❑ Other i i�:, .❑ Delta + Depth of Grout Seal Type of Grout ElIrrigation --Approx. Depth�� ❑ Eastern "t,- Surface Seal Installed by Repair Work Done ❑ Type of Pump "`H.P. art + r + State Work Done Weil Destruction ❑ Well Diameter Sealing Material (topY50'I `' Depth Filler Material(Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTIO. "{No septic system permitted if public sewer is i ..• "� ._ �6eilable within 200 feet 1 Installation will serve: Residence— Commercial Other• �'= Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: r Water table depth SEPTIC TANK.�4,. ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.'❑ Method of Disposal Distance-to nearest: Well Foundation Property Line y, LEACHING LINE Elng[ No. & Length of lines ? Total le h71ize_. a - .•-. FILTER BED El Distance to nearest: Well Foundation .Property Line. SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ 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. 11. 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 subcontracting 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 st call for all re uire inspections. Complete drawing on reverse side.` Signed XAT Title: �OYl��s–�S�-��.zr Date: !� DEPARTMENT USE ONLY Application Accepted by rys AA 1 Datet� tb Area ts J Pit or Grout Inspection by Date Final'Inspection by Date�� Additional Comments: ' _ f��"1 f*+ el to 11Stk 466-6781 El Lodi 369-5621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 I,I Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 IFEE NFO AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATEi PERMIT'NO. a EH 13-241RMI/R5) i�0 EH 1428