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I APPLICATION FOR PERMIT Dk SAN JOAQUIN LOCAL HEALTH DISTRICT t 1601 E. HAZELTON AVE., STOCKTON, CA f i � Telephone (209) 466-6781 ('I ' 2 $ i PERMIT EXPIRES 1'YEAR FROM DATE ISSUED (Complete in Triplicate) ENVIRO!IrIE.'v�AL HEALTH i 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 Z_� �dZ?Z d1 N,,F_ R.,Z2 City Lot Size PM Owner's Name F Address P. -,P. Phone r'+� Contractor ddress 4 !� License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION *je4P 0W_C-�'� 4YTEM REPAIR ❑ OTHER ❑ Y_ -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 D Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing omestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications' ('l Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout _. c i I I Irrigation —.Approx. Depth l I Eastern Su1j1ce Seal Installed by _ Repair Work Done ❑ Type of Pump H.P. State Work pone 1.N 2022 A i J- Well Destruction ED Well Diameter Sealing Material (top 50'1 U �� Depth Filler Material (Below 50') F SEPTIC WORK: NEW INSTALLATION f'I REPAIR/ADDITION 1 I DESTRUCTION i I (No septic system permitted if public sewer is available within 200.feet.) Installation will serve: Resi Commercial_ Other Number of living units: Number of be r � ~ 11 Character of sail to a depth of 3 feet: - Water table depth SEPTIC TANK ❑ Type/Mfg �f { acity No. Compartments PKG. TREATMENT PLT. P_ 4 Method of Disposal Distance to nearest: Well Foundation Line LEACHING LINE ❑ No. l3 Lengthrof lines_ Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line 111 .1 A SEEPAGE PITS_ 11 Depth Size Number SUMPS Ll Distance to nearest: Well.4 �A r Foundation Property Line DISPOSAL PONDS ❑ t r ' f 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 thatlin the performance of the work for which this permit is issued, I shall not employ any person in such manner as to beborne subject to workman's compensation laws of California," Contractor's hiring or sub-contracting signature certifies the following: "I certify that ink`performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." f The applicant mu • a1L quired Complete drawing on r er ide, Signed X� Title: Date: 1 FOR EPARTM T USE ONLY J /r Application Accepted by I Date r �Lr I� Area Pit or Grout Inspection by 4 " Date Final Inspection by Date Additional Comments- -El-StF`466=6781 ❑'Lodi"'369=362'1-1 """'M- anteca 823-7164 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health P erm it/Services 1601 E. Hazalton Ave., P.O. Box 2009, Stk., CA 95201 �* V \,A\ INFO AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY DATE PERMIT'NO. ♦.EH13-21(REV. i 14 5) EH 14-2e ��