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IZI APPLICATION FOR PERMIT in Bonn SAN JOAQUIN LOCAL HEALTH DISTRICT Val 0 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE 1SSUEDFNVIRONMENTAI- HEALTH tComplete in Triplicate) PERMIT/SERVICES 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 2040 W. Wasshinqtnn Street _ City StoCkt.nn Lot Size PM Owner's Name Ca l —Far ,___Spy — Address Phone I Contractor ,fir_ Address 2825 E_ Myrt1i License No. 8 __Phone TYPE OF WELL/PUMP: NEW WELL EX WELL REPLACEMENT ❑ DESTRUCTION ❑ i i PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ tr.,� 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 �- O Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 8.1 nctie S Dia. of Well Casing 21 nche S f ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing SCH 40 PVC Specifications F1 Public ❑ Other Cl Delta Depth of Grout Seal 10 ft Type of GroutrpMpn t lhtnn t on i t1 I I Irrigation 2_5-,,Approx. Depth l I Eastern Surface Seal Installed by gr_oUt p nm-�_ _ Repair Work Done ❑ Type of Pump H.P. _ State Work Done r Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material {Below 501 _ TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION I I DESTRUCTION l I (No septic system permitted if public sewer is 1 available within 200 feet.) ! Installation will serve: Residence_ Commercial_ Other i 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 j I i LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property line i I SEEPAGE PITS l I Depth Size __ Number s 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 Di3trict. 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." The applic m t call for all requirW injqpections. Complete drawing on reverse side. Signed X Title: ,/// Date: I�V —T7 } } OR TMENT USE ONLY Application Accepted by Date J S- �a_ Ar Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: 0 Stk 466-6781 ❑ Lodi 369-3621 0 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 RECEIVED BY DATE PERMIT'NO. INFO C +.EH 13-24(REV.r/s 5) F 1 ! EH 14-29 i 33 G / 1 J—�J i