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�Foyy `� 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 (Complete in Triplicate) ES1VIftGFrrwi:TAL HEALTH Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein cFe€F2fAjf;rYbi6. 6n 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/7_C4" 277LI {t�1__t_�1/�-j City ' Lot Size PM (� Owners Name%L�1- l""SWT` 1 �7Addresss 1� L J-,4��J ,tj �/ Phone Contractor li�"r' Address /'� V'r�f 1'7 .-G License Nqt 6 13-2-S Phone 7 6 1 \ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION O' SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK I SEWER LINES DISPOSAL FLD. PROP. LINE C1` FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS (V� 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 17 Public ❑ Other fl Delta Depth of Grout Seal Type of Grout_. I I Irrigation —Approx. Depth I I Eastern Surface Seal Installed by - Repair Work Done (d Type of Pump H.P. 3 State Work Done_ Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I l REPAIR/ADDITION ( 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 SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments 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 Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that 1 have prepared this application and that the work_will be d_one 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: "1 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 or sub-contracting signature certifies the following:"I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applicant ,�'7-�s_t/c(�II for all required (iinns,p�ct, Complete drawing on reverse side. Signed Date: J ;Cn / FOR DEPART NT USE ONLY Q� Application Accepted by Date i7 11 " r J Area. L`z Pit or Grout Inspection b Date Final Inspection by�'// i .zt>�Y1�-r✓ Data �`-• _��3 Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6365 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE gMOUNT DUE AMOUNT REMITTED CK RECEIVED 13Y DATE PERMIT NO. NFO CASH ♦ EH 11241REV.vest EH N M