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Stle APPLICATION FOR PERMIT .11 a%, 'A SAN JOAQUIN LOCAL HEALTH DISTRICT s �A 1601 E. HAZE T ON AVE., STOCKTON, CA �T Telephone (209) 466-67$1 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED C ,n � �- Q tT (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 e'scribedAti''fiis application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules and R�julaiions of the San Joaquin Local Health District. Job Address ! City Loot Size PM Owner's Namey"— Address nJ �� a r n P!/ . !� �, Phone Contractor Addressg__ ,e Yifu 19 f License No f hane TYPE OF WELL/PUMP: NEW WELL C] WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR '�r 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 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia- of Well Casing Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 1-1 Public ❑ Other 1=1 Delta ,;Depth of Grout Seat } Type of Grout I I Irrigation __-Approx. Depth l I Eastern Sur aco Sedl Installe2l by Repair Work Done .,W Type of Pump ,5.-. WP. 7il' State Work Done. � Well Destruction ❑ Well Diameter Sealing Material (top 50'1 Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION l'l REPAIR)ADDI.TION l I DESTRUCTION lcl (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 r 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 11 h-..4-r -.�: Distance to nearest: Well Foundation Property Line r� LEACHING LINE ❑ No. A Length of lines Total lengfh/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line 5 I SEEPAGE PITS I I Depth Size _ Number SUMPS L� Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 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 D�trict. 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, Vshall 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: 1 certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion taws of California." The app' st call for all required ' spectio Com to drawing on raR'OZ2 ide. Signed X Title: � L Date: j—,–/,4�; F DIE TMENT USE ONLY Application Accepted by Date + t Area 213 Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 El Lodi 369-3621 ❑ Manteca 923-7104 ❑ Tracy 835-6385 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 PERMIT'NO. a.EH13-24 MEV.1/w 51 �•-(� G rp`�r' ~e3! I EH 14-26 mow// •C