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P HCE l,NJ ED APPLICATION FOR PERMIT RE SAN JOAQUIN LOCAL HEALTH DISTRI& 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 VIRONMENTAL HEALTH PERMIT EXPIRES 1 YEAR FROM DATE ISSUED +EN pERM1TISERVICES (Complete in Triplicate) Fol-- 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.t- 1ay� (`� D Job Address ' N"V ��fy4 e City s1- Lot Size ` fic e PM Owner's Name � GC4Lii� Jc Ck �` Address /� / l��1 �� Phone7' Contractor E=c.-t 1 Address �3�c.� S License No.112, Phone G //c TYPE OF WELL/PUMP: NEW WELL 2r WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER [i " DISTANCE TO NEAREST: SEPTIC TANK I? SEWER LINES 5S t DISPOSAL FLD. ? PROP. LINE �� FOUNDATION AGRICULTURE WELL ? OTHER WELL PITS/SUMPS -allo i INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS a 11 ❑ Industrial ❑ Open Bottom ElManteca Dia. of Well Excavation) Dia. of Well Casing ❑ Domestic/Private 2/Gravel Pack ❑ Tracy Type of Casing Q / Specifications * Public ❑ Other f-1 Delta Depth of Grout Seal x j 3" l ` Type of Grout I I Irrigation 351_Approx. Depth rv�Eastern Surface Seal Installed by peelr g M Ex _ Repair Work Done ❑ Type of Pump r1 H.P. State Work Done _ Well Destruction ❑ Well Diameter 1 Sealing Material (top 50') C-t'✓,pek& �C T�� j• Depth 3 i 1 Filler Material (Below 501 +. f ) TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) S7 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 I I Depth SizeNumber ' 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 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." Contractors 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 reverse side. .}_ Signed X Title: -L (_,C'_f t t'N.L"i ( C (..� Date: s /95? OR DE TM_ USE ONLY Application Accepted by Date (� Area Pit or Grout Inspection by F L 9i1t� Date ''Y1 Final Inspection by ��` Date Additional Comments: 1 •^ Q�vc...G¢„ ❑ 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 TED 44.4- INFO FEE AMOUNT DUE AMOUNT REMITK RECEIVED BY DATE PERMIT'NO. r II ♦ EH 13-241REV.lix sl ��