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ISAN JOAQUIN LOCAL HEALTH DISTRICT SAN JOAOUIN LOCAL HEALTH DISTRICT ENVIRONMENTAL HEALTH DIVMONCATION FOR PERMIT ENVIRONMENTAL HEALTH DIVISION SP L PE9MVIOAQUIN LOCAL HEALTH DISTRICT ��i S @T 1� -1'601 E. HAZELTON AVE., STOCKTON, CA RECEIV Telephone (209) 466-6781 12 PERMIT EXPIRES TYEAR FROM DATE ISSUED ��P 19$8 (Complete in Triplicate) ENVIRONMENTAL HEALTH Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the workll"li fpt s application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1662 for well/pump and the Rules and Reg rations of the San Joaquin Local Health District. �p , Job Address r ' A S G2 "" City Yr'bC,41m % Lot Size PM Owner's Name avo ere*llk.r Address /� -J/ii�r L1�/� �ll� P79a5G Phone �� ,,,,//^^ aryl.-/, �� j/ D Contractor�V_/c- I/l��itGfi��Address E�9tc�erFr� License No.""` 337 Phoripp~Qez-7 TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION e SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. POOP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFI 1 �lndustrial C7 Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ?Gravel Pack ❑ Tracy Type of Casing A-C Specifications 1 * Public OtheMwel-ol" ❑ Delta Depth of Grout Seal Zr27 Type of Grout&XAI' _ 1 i I Irrigation --Approxi Depth l I Eastern Surface Seal Installed by Repair Work Done ElType of Pump 04111"n H.P. °/`7 State Work Done _ Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material {Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION i 1 REPAIR/ADDITION 1.1 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 f LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS i I Depth Size Number SUMPS Cl 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 Il for owl M-W iFerYetspBctions. Complete drawing on ruse s1 ; Signed X Title: �/l/��•" _ Date: FOR DEPARTMENT USE ONLY Qom/ Application Accepted by Date �I�v o Area Pit or Grout Inspection by Date fJFiintaal Inspection by pm Date Additional Comments: S rem /�!� 10 eQ��I.eI ��J�Y_Lf1 l T. 00 S QYl� fes .. ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca "823-7104 ❑ Tracy 835-6385 7 _•.. ._ Applicant - Return all copies to: Environmental Heal�thff Permit/Services 1601 E. Hazelton Ave., P.O, Box 2009, Stk., CA 95201 1Litdt5 FEE INFO AMOUNT DUE AMOUNT REMITTED 1 CK 4 RECEIVED BY I DATE PERMIT" O. _ f ♦.EH 13-24(pEV.1/R 5) EH 14-26 If J