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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT ` 1601 E. WAZEL i ON AVE., STOCKTON, CA Telephone {209) 466-6781APR ., PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Zc f?�5V--42 (Complete in Triplicate) ENVIR0IVIENTAL HEALTH +fid�k�Fic+15EflVAI@ESThis app ^� Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install th i application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules and Regul ns of the San Joaquin t Local Health District. -T I�.5�t 3 s . i �rry I� led - -- W Cd t V, Job If ts:5f."_ _ )112 / I). City Lot Size PM Owner's Name I JI �r Address 20SSO PC4enr IS ] Phone XXL 3QZ3 ( n Contractor Address SalLa'I Q L�License No. a 113 Phone TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ ` A CY' PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK n071P , SEWER LINES DISPOSAL FLO. PROP. LINE r FOUNDATION AGRICULTURE WELL - OTHER WELL PITS/SUMPS .w,- v e ^ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ,f 171 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing _.� �h ❑ Domestic/Private % Gravel Pack ❑ Tracy Type of Casing Specifications M Public f_} Other fl Delta Depth of Grout Seal ?2011!, Type of Grout_- �t�J -_ D(Irrigation _Approx. Depth l I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P, State Work Done Weil Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 50') r TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I 1 DESTRUCTION I I fNo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other j 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 P 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 1 SEEPAGE PITS { I Depth Size Number K SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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 1. 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, l 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 applic ust call for all re 'ed inspectio s. Complete drawingnX ver a side. Signed X Title: Data: fy FOR DEPARTMENT USE ONLY Application Accepted by Date �2—� Area 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 I kHezelton Ave., P.O. Box 2009, Stk., CA 95201 0 FEE INFO AMOUNT DUE AMOUNT REMITTED CASA RECEIVED BY DATE PERMIT*NO. ♦ EH13-24 IREV.i/n 51 ^ t r EH 14-28