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lee %.., 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 JUL 19 1088 (Complete in Triplicate) ENVIROMEN��T�ApL��Hr�E�A�LTH ` Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the worFLWIaysLit ..ITfNY'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 of the San Joaquin Local Health District. ` Job Address 9�n S 3YlQ&4 . City ��(V. �Size PM Owner's Name Addresskbkaa ^�'— i1?19) J O t;L' r f� � — Contracts ddress Po PON c?)L, License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. POOP. 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 ❑ Delta Depth of Grout Seal Type of Grout `. I I Irrigation _.Approx. Oapth I I Eastern Su ace Seal Installed by _ W air Work Done /T r Repair (B" Type of Pump �� H.P. �i� State Work Done Well Destruction ❑ Well Diameter Sealing Material (tap 50') , r Depth Filler Material (Below 509 TYPE OF SEPTIC WORK: .NEW INSTALLATION FI REPAIR/ADDITION I I i DESTRUCTION I I (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._ Character of soil to a depth of 3 feet: Water table depth V N SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments r PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line he LEACHING LINE Cl No. & Length of lines Total length/size sl FILTER BED ❑ Distance to nearest: Well Foundation Property Line - SEEPAGE PITS - I I Depth - - Size - - - - -- - - Number I T SUMPS ❑ Distance to nearest:. Well Foundation Property Line DISPOSAL PONDS ❑ I thereby 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 D3trict. - Home owner or Ii nsed age 's sigg�mfifollowing: "I certify that in the performance of the work for which this permit is issued, I shall not employ any pe on in such ma ner act to workman's compensation laws of California."Contractor's hiring,or sub-contracting signature certifiesthe f lowin : "I certi at oft for which this permit is issued, I shall employ persons subject to workmantion laws of alifor a."The applica t mu a r req plate drawing on r si / L n Signed Title: '/ Date: u 3` R PARTMENT USE ONLY Application Accepted by ��Ir/V�yC//v �"^� Date / s-�;/�i7 `:Area _ Pit or Grout Inspection by He Final Inspection by ,G](,�L/f/ Date Additional Comments: C./J ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy M-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 9''-1201 r INE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED By DATE PERMIT No. a.EN f}M(REV.vxsf gs r EH 14M