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G a i AN =(APPLICATION FOR PERMIT �6iY JIN LOCAL HEALTH DISTRICT FEB T O �QaO 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 ENVIRONMENTAL HEW"IT EXPIRES 1 YEAR FROM DATE ISSUED- PERMIT/SERVICES (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This 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. I � � �I Job Address_2 33SV • �- City Lot Size PM �1 r. Owner's NamAd�dressj�1`3sy Phone �D Contractor t 0 Address& (- .'° '�+r- License No/ -373 73 Phone G �" TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER El - .DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial---- r ❑.Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing *Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications I'i Public Ll Other I ❑ Delta Depth of Grout Seal Type of Grout v I I Irrigation _Approx. DepVh I I Eastern Surface Seal Installed by _ Repair Work Done L•Y Type of Pump H.P. IS— State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 - -----.:xpth- Faller-Material-IBelow-50a - - TYPE OF SEPTIC WORK: NEW INSTALLATION 1:1 REPAIR/ADDITION I I DESTRUCTION I I (No septi6system permitted if public sewer is I available Within 200 feet.) Installation will serve: Residence— Commercial_ Other I Number o1 living units: _ Number of bedrooms I e 1 i,� r Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments J s PKG. TREATMENT PLT.❑ `t1 - MetWd of Disposal r Distance to nearest: Well J Foundation Property.Liner r LEACHING LINE ❑ No. & Length of lines ,I Total length/size r. ../ FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size /• Number , SUMPS Ll Distance to nearest: Well Foundation Property Lit e DISPOSAL PONDS ❑ 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 Dstrict. III 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."Contnictor'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 Califomia." 1 The applicant at Ilfor II required inspections. Complete drawing an reverse side. 1 (. r Signed %A`4itle: I Data: / o OR DEPARTMENT USE ONLY 99 Application Accepted by Date Area Pit or Grout Inspection by DFinal Inspection by—�� Date _7f_-Zd Additional Comments: ❑ Stk 466-6781 ❑ Lodi 3693621 ❑ 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 AMOUNT DUE AMOUNT REMITTED OK RECEIVED BY DATE PERMIT'NO. E INFO CASH "� EN 1 A •.ENI}N IREV.416 I Irn51 �(i�llO �/