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-•.`. APPLICATION FOR PERMIT N JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PY PERMIT EXPIRES 1 YEAR FROM DATE ISSUEDC(O ` 4 yip `�.a�4n—?v::- (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. Job Address /'/a/^ City FSC410n __ Lot Size PM Owner's Name �'U✓ �G 14 0 dd Address ME - Phone Contractor 05be,,ke ej JS�e"*Q i /- Address 4.d,,/o License No. Phone_ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER N Say J ►/rS S (3) 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 7 �— _ Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing 4—C Specifications I'1 Public W Other n Delta Depth of Grout Seal �' O Type of Grout 1 1 Irrigation Z--C-)"Approx. Depth I 1 Eastern Surface Seal Installed by - Repair Work Done ❑ Type of Pump H.P.__ State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 50•) -- TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewertis available within 200 feet.) O Installation will serve: Residence_ Commercial f Other NAber of living units: Number of bedrooms Ch actor of soil to a depth of 3 feet: Water table depth SEP C TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Q Distance to nearest: Well_ Foundation Property Line Y� LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: ell Foundation Property Line SEEPAGE PITS I I Depth Size Nu ber SUMPS LI Distance to nears: Well Foundation Property Line DISPOSAL PONDS 1-1 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 Di§trict. 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: "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." SAN JOAQUIN LOCAL HEALTH DISTRICT The applicantmpsglcall for al� 41 Id inspections. Complete drawing on reverse side ENVIRONWENTAL HEA!__ SIV Sl0N Signed X Title: IE0A ' FO EPARTMENT USE ONLY Application Accepted by _—f Date `-/-y� Area Pit or Grout Inspection by Date Final Inspection by��,q� LL Date Additional Comments: A ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ M teca 823-7104 ❑ Tracy 835- 5 5 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY DATE PERMIT'NO. INFO a.EH13211REV.1/851 EH 14-2E