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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICTvstzz t�, ` ._, 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 UUU PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) ENV)ROMENI TAL Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work caCibn 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 the Joaquin Local Health District. ��TT + Job Address ` `,' C hewkF L-GT n E' City Ub / lot Size PM _ / . J. ��EIC)KcC L�Z/7 E Owner's Name __—_ Address Z&4),___� Phone S'JG7fl Contractor R//k-knil 1 Ez cry l a.�k16 Address.�� K/7�' � k' v'/�64 License No.43-7 J2f, Phone tL/b)'771-0-724- TYPE 77/-0,724TYPE OF WELL/PUMP: NEW WELL C1 WELL REPLACEMENT ❑ DESTRUCTION O PUMP INSTALLATION LI SYSTEM REPAIR [7 OTHER ) /Y�o.+r�nhJ We 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 v C1 Industrial El Open Bottom ❑ Manteca Dia. of Well Excavation S// _ Dia. of Well Casing Cl Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing s Ab PVC Specifications Ce.,,,' F! Public (1 Other I Delta Depth of Grout Seal '`gyp�_S� yType of 2:7�� I I Irrigation -.___ Approx. Depth I I Eastern Surface Seal Installed by A// T rmth Dr.I %,q /dfLj�r, (',-nsw/7arA S Repair Work Done [J Type of Pump _ H.P. State Work Done _ i Well Destruction i I Well Diameter _-_ Sealing Material (top 50'1 ryi ,t V, well m Depth ''6S-70 Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted it public sewer is 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 SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. L.1 Method of Disposal Distance to nearest: Well Foundation_ Property Line LEACHING LINE Ll No. & Length of lines Total length/size FILTER BED L) Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth _- Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS 1-1 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, 1 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,1 shall employ persons subject to workman's compensa- tion laws of California." The applicant st call f ll r Auirednins_pections. e. b/ZLWlhy Signed �' Title: tJ Date: 3 on R DEPARTMENT USE ONLY Application Accepted by (/ . Date 3�3 r 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 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. z INFO EH 13-24 IREV.