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APPLICATION FOR PERMIT �..� SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE IWIWP �j_ HEALTH DISTRICT (Complete in Triplicate) 1. ENVI UNNILrvIAL HEALTH DIVISION t SPECIAL PERMIT Application is hereby made to the San Joaquin Local Health District for a permit to construct and/b14tall 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?'.IIcV- 1;.C,It �'Z- �L'�t� ►�'�/��} City S `!`�'' Lot Size PM Owner's Name Ch �3 ��GfG�- Address Cd71 (4,11 Phone 1941f e�2 Contractor 4e C--,f Address I-V-L:3 I'Z-rvt/ 'Z41f� icense No. �lybb7� Phone 7- 5��7 TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ o DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE X T FOUNDATION /6 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 Z ❑ Domestic/Private ravel Pack ❑ Tracy Type of Casing Y 1l L Specifications FI Public ❑ Other I l Delta Depth of Grout Seal �'�` Type of Grout C=2o_� _ I I Irrigation Approx. Depth I I Eastern Surface Seal Installed by RerN r- 17D.1;h pair Work Done ❑ Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 —_ TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION 1 1 (No septic system permitted it 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.taftle depth_ SEPTIC TANK ❑ Type/Mfg Capacity I ' No. Compartrlteni s 1 PKG. TREATMENT PLT. ❑ I,, Method-.of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Tofat length/size` FILTER BED Cl Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size _ Number SUMPS L.1 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS n 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 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 ralifornia." 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 must call for all required inspections. Complete drawing on reverses/side. Signed X, a i✓ 7f!Kc� Title: ��✓4 Date: j r1 FOR DEPARTMENT USE ONLY Application Accepted �Q Date by Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 O Lodi 369-3621 O 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 AMOUNT DUE AMOUNT REMITTED CE* R RECEIVED BY DATE PERMIT-NO. INFO ♦ EH 13-211REV.rin5r -• EH 11•TB J^�