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APPLICATION FOR PERMIT SAN JOAQU1,N LOCAL HEALTH DISTRICT ?rI r?_3 1601.E. HAZEL ON AVE., STOCKTON, CA r,, , Telephone 1209) 466-6781 i. ,� 2 - PERMIT vPERMIT EXPIRES 1 YEAR FROM DATE I6SUEEt (Complete in Triplicate)I NVIROpFRfd1r, AL HEALrH die Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein i 4m 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 , p 5'F ! /�� .. City 5SOOV Lot Size cFAQ PM `Owner's Name Ela_ Address J925? D Qr-iVr phone 1610DETM C4. L ` Contractor Q�j�nse No.- �f2� Phon %i TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ _ ..... ! PUMP INSTALLATION ❑ SYSTEM.REPAIR.❑—.__ -.OTHER❑ - DISTANCE TO NEAREST: SEPTIC TANK - SEWER LINES DISPOSAL FLD. PROP. LINE - 4 t -FOUNDATION AGRICULTURE WELL OTHER WELL _^�"PITS/SUMPS INTENDED USE ,F TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS J - N� r) ❑ Industrial 13 Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing NJt f El Domestic/Private iSGravel Pack ❑ Tracy Type of Casing G _ Specifications Fi]P�ublic El Other ❑ Delta Depth of Grout Seal [ 427Type of Grout i'llrrigation Approx.l Depth 0Eastern Surface Seal Installed-bV ; Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction I❑ Well Diameter Sealing Material (top 501 Depth Filler Material {Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is /�, 1 s. available within"208 feet.) � al Installation will serve: Residence! Commercial— Other Number of living units: Number of bedrooms T.. . Character of soil to a depth of 3 feet:! Water table depth ! ; -SEPTIC TANK 12Type/Mfg �"' Capacity No. Compartments 'f`.,PKG. TREATMENT PLT. ❑ I Method of Disposal . .� .., a Distance to nearest: Well Foundation Property Line i LEACHING=LINE ❑ No. & Length of lines Total length/size FILTER BED J-0 Distance to nearest: Well Foundation Property Line -moi - i - SEEPAGE PITS x❑ Depth Size Number SUMPS _. ❑� Distance to nearest: Well Foundation Property line DISPOSAL PONDS El- ✓1�_.� _ _ . ._-_ _ _ _ _._-�._ 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 E 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." s The applicant t c011 r all re ed i spections. Complete drawing on r yerse sid _ } k Signed X Title; cl ztnw ef4m Date: FOR DEPARTMENT US NLY Application Accepted by Date / J�`7"`—� J Area t!�2 ' Pit or Grout Inspection by Date Final Inspection by Date s Additional Comments: rTnL . .-7- 9-7 4V �` Jr�� G✓> EJ Stk 466-6781 ❑ Lodi 369-3621. El 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 INFO AMOUNT DUE AMFEEOUNT REMITTED CASH RECEIVED 8Y DATE PERMIT`NO. + EH 13-24 IREV.7/e5) EFI1428 .,rX7 S`�j„