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N APPLICATION FOR PERMIT � � �Il ll SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 SLP PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) ENVIROM FERMIT/ENSRY CFSAL tT Apppcation is heoby 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. A /- Job Address O-�t�/a�. O.LP��A AA�w ' City /JLC Lot Size PM Owner's Name 7Y,-,p�11'a� 'Y G] rLa't Addms5�.073 c�cge,V3LusYPhone .50rtz �_r..a. ftp-�aysa Address �3 �4. Aa ,A-�- Jr-Qe 4 3-3 ^�� I e e No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION)( SYSTEM REPAIR ❑ OTHER ❑ I 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 ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 1jDomestic/Private ❑ Gravel Pack ❑Tracy Type of Casing Specifications M Public ❑ Other fT Delta Depth of Grout Seal Type of Grout�. I I Irrigation „��..JJ _Approx. Depth I I Eastern Surface Seal Installed by _ Repair Work Done V4 Type of Pump H.P. . rim-9— State Work Dcne;j Well Destruction ClWell Diameter �--- Sealing Material (top 509 -P -,�Glsyt eld (,r.e.QQ� ti. Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I I INo septic system Permitted if public sewer is 31 available within 200 feet.) O Installation will serve: Residence_ Commercial_ Other d ` Numbs of living units: _ Number of bedrooms Character of soil to a depth of 3 feet: Water table de pth SEPTIC TANK ❑ Type/Mfg Capacity. ompartments PKG. TREATMENT PLT. ❑ d of Disposal Distance to nearest: Well. Foundation LEACHING LINE ❑ No. & Length of lines ToFILTER EIED ❑ Distance tonearest: Well Foundation e00 SEEPAGE PITS I I Depth Size NSUMPS 0 Distance to nearest: Well Foundation e DISPOSAL PONDS ❑ 1 hereby comfy that 1 have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, antl rules and regulations of the San Joaquin Local Health Diltrict. Home owner or licensed agent's signature cartifies the following:'9 certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manna,as to become subject he workmen's compensation laws of California.” Contractor's hiring or sub-contracting signature certifies the following:'9 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 mu 11 oil requiredd-5 actions. Complete drawing on re me elde. / Sig rad (I Title: L-�_. Date: 27 'f FID DEPARTMENT USE ONLY " Application Accepted by �� "'-� Date _/ Area Pit or Grout Impaction by Data Final Inspection by Dam Additional Comments: E/ ❑ Stk 466-6781 ❑ Lodi 3693621 ❑ Manteca 8737104 ❑ Tracy 8356385 Applicant- Return all copies to: Environmental Health Permit/Samicas 1501 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 1 FEE INFO AMOUNT DUE AMOUNT REMITTED CK RECEIVED 6Y CASH Da=- ..EN r3N IflEV.VMeI EN 14 26 ta ct