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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA An 9''al F ' "'Cy Telephone {209} 466-6781 *` PERMIT EXPIRES TYEAR FROM DATE ISSUED FEB 2 p !�� ENVIRONMENT .99 (Complete in Triplicate) EN MENT (�� 'i- Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work er i e�c�!J4 ` t WLT_14 is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and I f (�''NN �i Joactuin Local Health District. Job Address 2)©-5-SOIX so City Lot Size PM Owner's Name EWA,-0&_ Address Phone Conlractor Address P2 W14 � icense NoJ44A Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION Ll -SYSTEM REPAIR OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 0 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Womestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications F1 Public Cl Other ❑ Delta Depth of Grout Seal Type of Grout _ I I Irrigation t_Approx. Depth I I Eastern r Surface Seal Installed by Repair Work Done Type of Pump4sAA_- H.P.b� State Work Done Well Destruction ❑ Well Diameter Sealing Material [top 50') Depth Filler Material I Below 5011 IV TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is Q available within 200 feet.) V)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 SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments �y PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line ' r LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS Z i1"Depth" -Size _ Number SUMPS Ll Distance to nearest: Well Foundation `""Property Eine- - DISPOSAL PONDS ❑ 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. r 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, 1 shall employ persons subject to workman's compensa- tion laws of California." The applicant mus c II for all required inspections. Complete drawing on reverse side. _ 1 Signed X — Title: Date: . .`` FO DEPARTMENT USE ONLY 2 Application Accepted by Date Area Pit or Grout Inspection by Date Final Inspection by Date / I Additional Comments: I ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 II Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 I FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. +.EH132/IREV.riysi ''7'" ko EH 14-28 f i