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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT = f i,;Q,�Y V�: 1601 E. HAZEL I ON AVE., STOCKTON, CA ' Telephone (209) 466-6781 DEC 198 PERMIT EXPIRES j� r v. C� T YEAR FROM DATE ISSUED . 7 (Complete in Triplicate) `�_ LNVIROMIEN7 _ i PERMt7 RL HEALTH Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein descri E made in compliance with San Joaquin County Ordinance No.50 for sewage or No. 1862 for wall/pump and the Rules and Ft, ulatio Agan n is Local Health District , :. p P and-Re Joaquin 312 r .. Y 2�vf -{Po -e9 �! Job Address I�ZL`rt%frLlr ,.tarty Lot Size ply 4 Owner's Name Address _p�1g6�C f•Qh�� Phone �7 Contractor Address - 6 4 iq�icense No. d 3 Phone �l�b TYPE OF WELL/PUMP: 1 NEW WELL j WELL REPLACEMENT ❑ DESTRUCTION ❑ t PUMP INSTALLATION ❑- SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK _t��._ SEWER LINES DISPOSAL FLD. n671 e,PROP. LINE FOUNDATION — AGRICULTURE WELL OTHER WELL —4)' �L�� PITS/SUMPS � _ _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS T ❑ Industrial El Open Bottom ❑ MantecaDia. of Well Excavation - Dia. of Well Casing ,❑ Domestic/Private Gravel Pack ❑ Tracy Type of Casing_ �5f �� Specifications ❑ Public ❑ Other �! ClxGLtt[ ❑ Delta Depth of Grout Sea! � Irrigation pe of Grout d R Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work bone ❑ Type of Pump H.P. s Lll State Work Done Q Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No stem septic system V permitted if public sewer is - Installation will serve: Residence�' Commercial— Other available within 200 feet.) Number of living units: Number,of bedrooms Character of soil to a depth of 3 feet: C� SEPTIC TANK c Water table depth r 4 ❑ Type/Mfg PKG. TREATMENT PLT. L] Capacity No. Compartments � Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No:.& Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line # r SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line - DISPOSAL PONDS Cl: Al_ . _ — -a --•— . - ! hereby certify that i have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, rules and regulations of the San Joaquin Local Health District. and 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 s 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." t 1 The appli ant ust call for all re fired inspections. C pie dr 'ing on rever side. i Signed ` Date: FO DEPART NT USE ONLY Application Accepted by � Date_7A4i5__ Area r Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ; ❑ 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 ' S f FEE INFO AMOUNT DUE AMOUNT REMITTED 5�pr n CASH RECEIVED BY DATE PERMI7�N0. } + EH 13-24{REV.tits 5) a 761,Da EH 14-28 } - 1