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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CASAN JOAQUIN LOCAL HEALTH DISTRICT Telephone 12091 466-6781 ENVIRONMENTAL HEALTH DIVISION PERMIT EXPIRES )'YEAR FROM DATE ISSUED SPECIAL PERMIT (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. A yy t 164 F.-k.ellsAvP-City S�cck/z.— Lot Size PM Job Address 5n T� f C NA� 1" Mtluy� A1M: ?tw ff4�JSi C � 9�P-ZEZ G of `�Ti4b,,r' Address S � Phone Owner's Name f'�h � Contractor 6 �a'e.,wi�' Address Z"5 2; � ��' License No V"'74 Phone S3 — n67 TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ '/6G DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES Gy DISPOSAL FLD.. � PROP. LINE.— FOUNDATION. Z4c— AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Z�.. ❑Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 1r Dia. of Well Casing ❑ Domestic/Private nGfavel Pack ❑ Tracy Type of Casing 1?✓G Specifications I"I Public ❑ Fiber Ll.Delta Depth of Grout Seal Type of Grout_ �c-c...r.1_t._ I pl„i µ'� 6 4 _Approx. Depth I I Eastern Surface Seal Installed by 4'v pau Work one ❑ Type of Pump H.P. rk e Welt Destruction ❑ Well Diameter Sealing Material p Depth Filler Material 10 w 1 TYPE OF SEPTIC WORK:. NEW INSTALLATION I - REPAIR/ADDITION I I S IM 1 1 aNailaeptic system m peleaf tted it public sewer is vle.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 Capacity �lrfr"t Nof"�bmp ([mens SEPTIC TANK _ ❑ Type/Mfg �il PKG. TREATMENT PLT. ❑ t ? �Meth'odwt uls¢q�al�f Distance to nearest: Well Foundation Property Line p LEACHING LINE ❑ No. & Length of lines Total length/size Gr FILTER BED El Distance to nearest: Well Foundation PropertyLine _ r SEEPAGE PITS 11 Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line _ DISPOSAL PONDS ❑ 1 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 District. 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 candies 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 must call for all required inspections. Complete drawing on reverse side. n D� cle, orh— =. frs�itla: G Date: Signed X�.r ' —i FOR EPARTMENT USE ONLY q� D Application Accepted by // Date GAG a Area Pit or Grout Inspection by /tel Date N c" Final Inspection by Date Additional Comments: El Stk .466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 \ Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 • \ FEE I AMOUNT DUE AMOUNT REMITTED C IZ flECEIVED BV DATE MPERMIT INFO -... `EH 14.n---V.