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APPLICATION FOR PERMIT SAN JOAQUI N LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA NOV 19'8j,- Telephone (209) 466-6781 EWRONMENTAL HEALTH PERMIT EXPIRES 1 YEAR FROM DATE ISSUED PERMIT/SERVICES o- (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 DiWllct. -Z771 5o <_ r Job Address City Lot Size PM or- Owner's Name Addres -3 N Cr�RJ'L®--� ` Phone �� +�7 � S Contractor � � %+ Address 0 & License ho. 6 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 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing E*Oomestic/Private 1:1 Gravel Pack ❑ Tracy Type of Casing Specifications ! l'1 Public n Other ❑ Delta Depth of Grout Seal _ p , t � Type of Grout I ! irrigation __-Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ T r ,.> - 'J Type of Pump.. H. !State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') 4 y Depth I Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I f INo septic system permitted it public sewer is s available within 200 feet.} Installation will serve: Residence Commercial i Other i •'� ,,,Number of living units --Number-of-bedrooms d - r Character of soil to a depth of 3 feet: �- SEPTIC TANK ❑ Type/Mfg Water table depthCa acit C' p Y No. Compartments • PKG. TREATMENT PLT. 171 - ' ' Method of Disposal Distance to nearest: Well Foundation Property Line r LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED IDDistance to nearest: We11 Foundation Property Line SEEPAGE PITS 11 Depth 4 Size Number--} SUMPS Ll Distance too nearest: Well FoundationProperty 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."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." 1 The appficant_!auVjaII for all require in'spectidhs._Complete drawing-on reverse-side— Signed everse•side.�.� g Si rled X [� - Title:_ _ Date: FORD ARTIVIENT USE ONLY Application Accepted by y I /1� Date !� � ! 7 Area= / Pit or Grout Inspection by Date :Final Inspection by 1 —Date Additional Comments: 0 Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Trac y 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave, P.O. Box 2009, Stk., CA 95201 I FEE AMOUNT DUEAMOUNT REMIt ED' ..: CK INFO CASH RECEIVED BY DATE �• PERMIT'NO. +.EH 13-24(REV.t i x 51 r�S•�� EH 14-2e ��y��75O