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^+ �: APPLICATION FOR PERMIT ; SAN JOAQUIN LOCAL HEALTH DISTRICT Ala 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 d10,B8PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 2 � (Complete in Triplicate) EWrROMEN �'L 41EAL.TH Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein f ftit : �l� 'atidn is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules and Regu ations of the San Joaquin Local Health District. Job Address sw S J. Cit Lot Size PM Owner's Name Address sxvr Phone 17 /� �� Contracto Address r Gv License Nt g� — Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION X1, SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing gDomestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications l'l Public ❑ Other 1-1 Delta Depth of Grout Seal Type of Grout_—, I I Irrigation _Approx. Depth I 1 Eastern i Surface Seal Installed by �✓�V Repair Work Done [I Type of f ump,.�/j" 4— H.P. Il�r State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material iBelow 501 ` TYPE OF SEPTIC WORK: NEW INSTALLATION {1 REPAIR/ADDITION I I DESTRUCTION 11 iNo septic system permitted if public sewer is available within 200 feet.) 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 fid. PKG. TREATMENT PLT. ❑ Method of Disposal Vl` Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size Flt-TER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I 1 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. Home owner or licensed agent's signature certifies the following: "l certify that in the performance of the work for which this permit is issued, I shall not employ any parson in such manner as to become subject to workman's compensation laws of California." Contractors hiring or sub-contracting signature certifies the following: 1 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 m st call for all re .red inspections. Complete drawing ,on�everse side. 2 Signed X Title: Dat U FOR RTMENT USE ONLY 7 Application Accepted by 5��7 Date L rea 9.5 I� Pit or Grout Inspection by Date Final Inspection byZ2Dat �` Additional Comments: ❑ 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 FEE AMOUNT DUE AMOUNT REMIED CK TTRECEIVED 6Y DATE PERMIT'NO. INFO CASH i EH 13-24(REV.i/m5) 2y- 1-7pw EH 14-28 1 k/— ��, --e— , 41—