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ji,R APPLICATION FOR PERMITL5AN JOAQUIN LOCAL HEALTH DISTRICT n1988V1601 E. HAZELTON AVE., STOCKTON, CA PrP Telephone (209) 466-6781 ENVIROMENTAL HEAIE�IERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) KRMtT/SERVICES 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. Job Address [/ � 77. 91r /`T'wCl✓ U-C+ / ( City Lot Size PM < 1 / I� Owner's Name ^)_ /f ''` _ /'Address �l V7(7 ��(''J�'� 9�f Phone �C 0Qw Contractor `Qe, ` O � Address 1`b. -� `-��[. �'i� License Nq�. :3�3 Phone/- - TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ \ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ \ DISTANCE TO NEAREST: SEPTIC TANK .SEWER LINES DISPOSAL FLD. PROP. LINE O FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ DPen Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing I1�YOomestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ('1 Public ❑ Other C1 Delta Depth of Grout Seal Type of Grout I I Irrigation _.Approx. Depth I I Eastern �Sufface S I Installed by _ Repair Work Done 0' Type of Pump . H.P. / y� State Work Done r Well Destruction ❑ Well Diameter Sealing Material (top 50'I Depth Filler Material (Below:501 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I 1 (No septic system permitted if public sewer is available within 200 teat.) 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 11 Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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 DiAtrict. 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, 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: "1 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 applica ust ll for II r-equi d inspections. Complete yy drawing onreverseside. Signed X � ,. �'1F'tie: �YV Date: ^u 00 (,,_FORfIEPARTMENT USE ONLY Apptication Accepted by ZL—dLL Date n Area )� Pit or Grout Inspection by Date Final Inspection by k Date F� Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 623-7104 ❑ Tracy 635-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AM UNT REMITTED I CASH RECEIVED 6Y /DATE PERMeeeIT'NO. ..ER 13.24 IREV.If 5) EH 14-M �J �O