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4' APPLICATION FOR PERMIT iL f ZSf g� SAN JOAQUIN LOCAL HEALTH DISTRICT �S" `� W 0 r 1601 E. HAZELTON AVE., STOCKTON, CALL Telephone (209) 466-6781 Q S D e' W J�f!D tc PERMIT EXPIRES TYEAR FROM DATE ISSUED n III C�� (Complete in Triplicate) -�q i )P_�, o - f t :GJ4 C e M n c l f Application is hereby mad to the San Joaquin Local Health District for a permit to construct and/or install thepwor r- described.escribed. 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 f the San Joaquin Com. Local Health District. ��Y1 S a cC' a nn [] Job Addresslel"1►►')ft'�O �C`f T ��// City Lc t Size PM I Owner's Name yt4tugt-3 �ddress Phone�. ��k 8 2 0 ,qy-ass a Contractor GL? AddresTkok-ftia"i—C-4, License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER HO le 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 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ^! ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications /_ i'1 Public Ser3M�{, 171 Delta Depth of Grout Seal Type of Grout&`��_`!"C. I I Irrigation prox. Depth I I Eastern Surface Seal installed by _ Repair Work Done ❑ Type of Pump �_ H.P. ` State Work Done Well Destruction L] Well Diameter 3-Y Sealing Material (top 501 Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION I.1 DESTRUCTION l 1 (No septic system permitted if public sewer is l� available within 200 feet.l Installation will serve: Residence— Commercial— Other I Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth }1, SEPTIC TANK ❑ 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 lengtWsize FILTER BED ❑ Distance to nearest: ' Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ i 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." 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 applicant must tali for all requir nspectiom. Complete drawing o reverse side. f Signed X Title: er Q Date: 7 / 8 I FOR DEPARTMENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection by pD a Final Inspection by Date ~ wil l Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca -7104 ❑ Tracy 835-6385 j Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE /PEERRMIT NO. + EH13-24 iREV.i/n 51 EH 14-28