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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED FEB 1 � (Complete in Triplicate) ENVIRONMENTAL HEALTH Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the woRE�a`1, W,YrS�, -M3rb_ lication 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 t e an Joaquin Local Health District. Job Address LA I '10 K n, RoA City L-0 t� I Lot Size PM Owner's Name L-no Atli Address Phone v i S Contractor �5Address zf� I License No.� Phone 31-3zlo , TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION 1$'�(��I, 04rw4 SYSTEM REPAIR Ll OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK l " SEWER LINES DISPOSAL FLD. POOP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL FPROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom —O.Manteca Dia. of Well Excavation Dia. of Well Casing Vr�mesticl ❑ Gravel Pack �❑ Tracy Type of Casing Specifications 1 ublic ❑ Other �"H 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 , Nsj b _ H.P. i ` State Work Do0 Well Destruction ❑ Well Diameter-' Sealing Material Itop 50' �A ne PA Depth Filler Material (Below 501 (0&6 _ TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIRIADDITION i I DESTRUCTION I I INo septic system permitted if public sewer is N 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 r 'SEPTIC-TANK""""""''❑"'Type/Mfg Capacify` No. Compariments PKG. TREATMENT PLT. © ;. 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 SEEPAGE PITS I I Depth Size Number SUMPS L� Distance to nearest: Well Foundation Property Line S ." DISPOSAL PONDS ❑T._ hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, aj rules and regulations of the San Joaquin Local Health DRarict. 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 of sub-contracting signature certifies the following: "I certify that in the performance of the work for h this permit is issued, t shall employ persons subject to workman's compensa- tion laws of C ia." The applic t u re di)nactions. Complete r !`��r � tS� Signed X le: Date: f 1 FOR EPARTMENT U7 ONLY L h Application Ac Date .2��7' V Area i Pit or Grout Inspection by Date Final Inspection bFf 4 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 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT"NO, INFO CASH ♦.EH13-24)REV.1/015) t7 EH 1428