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e v.*,( 6LrvA✓rJ Grclah'y _ ! APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT IE � ` 1601 E. HAZEL T ON AVE., STOCKTON, CA V'— I� Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (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 Josquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. y M- Job Address City Lot Size PM hjl / A7 07`� Owner's Name Address / �l�F� i OLA2 Phone ` "ge, 1 - !r aye-�1i, � 1 'r Contractor's Name g— License No. Phone TYPE OF WELLIPUMP: :i! NEW WILL lk' WELL REPLACEMENTTA DESTRUCTION D TEM it PUMP INSTALLATION SYSREPAI ❑ OTHER ❑ DISTANCE TO.NEAREST: SEPTIC TANK SEWER LINES .} DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS �F INTENDED USE TYIPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS �Q ❑ I `dustrial F-10pen Bottom Manteca Dia. of Well Excavation Dia. of Well Casing *bmestic/Private Gravel Pack ❑ Tracy Type of Casing IRV G 1&0� r Specifications _ 'Public LI (liar El Delta Depth of Grout Sear Type of Grout y: Irri4ation pprox. De t d ❑ Eastern 3Surface Seal Installed by 9 Repair Work Done 'M 'Type of Pump H.P. State Work Done i Well Destruction '❑ WeIIIDIa eter - Sealing Material-(top 50'). f� i r✓ Q�lJ G.j Dii Filler,Meterial (Below 50') TYPE OF SEPTIC WORK: NEW IN ALLATION E3REPAIR/ADDITION ❑E DESTRUCTION EJ {No septic stem permitted if public se er is Ak .< s available within 200 feet.) G� vc. Installation will serve: Residence_ Commercial_ Other s '" r. 1 I Number of living units: I1 Number.vf bedrooms- __u-a_ Character of svil.to a depth of 3 feet: - Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments - PKG. TREATMENT PLT. ❑ 11 "� = * 3Method of Disposal �1 3 Distance to nearest: Well Foundation Property Line F LEACHING LINE ❑ A.. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line IN SEEPAGE PITS ❑ Depth Size Number. SUMPS It Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ElI f t- � 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 riot' 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 comperisa- tion laws of California." I�I �. The applicant must call for Il required inspections. Complete drawingo verse side. 4`r Signed X tu1 Title: Date: FOR DEPARTMENT USE ONLY - JU Application Accepted by Date f Se4l ILI, Ar a ° Pit or Grout Inspection by I Date S Final Inspection by Date Additional Comments: u� . ❑ 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 IFEE NFO AMOUNT DUE AMOUNT REMITTED C RECEIVED BY DATE "PERM;IT`NO�I. + EH13-24 TREY.101831 ,I EH 14-28 1