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SAN JOAQUIN LOCAL HEALTH DISTPICT APPLICATION FOR PERMIT ENVIRONMENTAL HEALTH D;VISi< A SAN JOAQUIN LOCAL HEALTH DISTRICT �. 1601 E. HAZELTON AVE., STOCKTON, CA REGEIV Telephone (209) 466-6781 'AN JOAQUIN LOCAL HEALTH DIStj2IT EXPIRES"11 YEAR FROM DATE ISSUED SEP 12 198$ ENVIRONMENTAL HEALTH DIVISI(MtS HM - - - — SPECIAL PERMIT (Complete in Triplicate) ENVIRONMENTAL HEALTH Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the@@ This application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Iijt r a=fu a Z of the San Joaquin Local Health District. i Jab Address WIfsk-1445 City Lot Size PM Owner's Name Address J�' /�«tel Phone u ` J Contractor �� Address L� L '�sG �-- License No._�V/Y ( Phone, fQzg TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ;Rr SYSTEM REPAIR ❑ OTHER ❑ DISTANCE-TO NEAREST: SEPTIC TANK Z,3' SEWER LINES Z•F� DISPOSAL FLD. PROP. LINE �. FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS t.y of V Xlndustnal ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of.-Well Casing ❑ Domestic/Private &Gravel Pack � ❑ Tracy Type of Casing ��/�a� Specifications L] Pub1� l Othe fW441'W F71Delta Depth of Grout Seal C� Type of Grout I I Iriigaiion —,-Approx. Depth I I Eastern Surface Seal installed by.aegr � .441C ,l1 Repair Work Done C1 Type of Pump &46M H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION I I DESTRUCTION l I Wo septic system permitted if public sewer is available within 200 feet.l 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 x FILTER BED ❑ Distance to dearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number 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. 1•� 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 Californi The applicant mu calif ins coons. Complete drawing on verse 'de. r^ Signed X Title: Date: i FOR DEPAJ)�RTMENT USE ONLY '7 Application Accepted by ' Date — Area Pit or Grout Inspection by Fki / Date h� Final Inspection by Date Additional Comments: (1 Y9 � IV L!F O ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 635-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED t K RECEIVED BY DATE PERMIT NO. +.EH13-21IREV.riKsl 39 1 EH 4-28 � J