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r OS (,y APPLICATION FOR PERMIT k-iPkAl_JOAQUIN LOCAL HEALTH DISTRICT j��+� r�- tnr DESCk'�1S�t3 R +1n r (S o,10+"1 A�eri E1PONE � rk, E. HAZELTON AVE., STOCKTON, CA TF�m v��5 AUTki0k�4�c �n'Ef5T5 DF `' p 0� S[.QLlklw r Telephone (209) 466-6781 DVkr�NkOfP PERMIT EXPIRES 1'YEAR FROM DATE ISSUED AWS OF1�k :Ak�CES. LOCAL (Complete in Triplicate) 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. f Y Job Address �� v /` r�'J �7 City Lot Size_ PM Owner's Name yp IA RX X t" Address fk/- Phone Q9� Contractor Sri(,, Address License No. Phone TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS �'- 0 Industrial 0 Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public L1 Other ❑ Delta Depth of Grout Seal Type of Grout I I Irrigation _Approx. Depth I I Eastern Surface Seal installed by Repair Work Done ❑ Type of Pump H.P. State Work Done \v Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRlADDITION l 1 DESTRUCTION)< (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 0 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 v FILTER BED ❑ Distance to nearest: Well Foundation Property Line ,r� SEEPAGE PITS I 1 Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS 0 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 Di1trict. 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." Contractors 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 applicapil must call for al equired inspections. Complete drawing on yreverse side. � ��/ Signed Title: �1�c9 v_p'�' .-._........._.._ Date: c} o L FOR DEPARTMENT USE ONLY Application Accepted by VeL-i% Date IN Area Pit or Grout Inspection by h Date Final Inspection by Date�/� -7 Additional Comments: __An �L�/•�7/� F1 Stk 466-6781 0 Lodi f69-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 � Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Silk., CA 95201 FEE INFO AMOUNT DUE AMOrUNT REMITTED CASH RECEIVED BY DATE PERMIT*NO. +.EH 17-24(REV. 5) EH 14-28