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a APPLICATION FOR PERMIT � t �l 5 ": .R SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEJON A�V'E., STOCKTON, CA c_-P Telephone (209) 466-6781 } PERMIT EXPIRES 1YEAR FROM DATE ISSUED F_NV1ROMENTAL HEALTH (Complete in Triplicate) VERMIT/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 V AP-11 CAV1Pof Size PM w� Vt�ICPa tA Owner's Name Iyt��L � Address Shone w Contractor&'V�R. soNeI41 Address �o ��Q 21� License No. 2,3 TA Phone [� TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTE ;REPAIR ❑, OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES f %,DISP,OSAL FLD�. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial- ❑ Open Bottom ❑ Manteca Dia. of Well Excavation i Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 1 M Public n Other j F1 Delta Depth of Grout Seal = Type of Grout 1,1,-Irrigation _,_Approx.-Depth l I E stern Surfac Seal Installed by _ Repair Work Done t Type of Pumpt� H.P. ) State Work Hone Well Destruction ❑ Well Diameter Sealing Material (top 50') l 1 Depth Filler Material (Below 50') ' TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION LI DESTRUCTION [ I (No septic system permitted if public sewer is P available within 200 feet.l Installation will serve: Residence—j Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet:4f Water table.depth i r' 'at sar ; J` - SEPTIC TANK © Type/Mfg ttl ..t4 I I Cap$cr No. Compartments PKG. TREATMENT-PLT' tyle hod of p'tsposal Distance to nearest: Well - - J i Fouhdatii n� x;7.j. Property Line .I y LEACHING LINE ❑ ' No. & Length of lines Total length/s ie FILTER BED ❑ Distance to nearest; Well Foundation Property Line SEEPAGE PITS I 1 Depth f Size Number {{ SUMPS Ll Distance tornearest: Well Foundation Prope6 Line DISPOSAL PONDS ❑ j t I hereby I y t have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules a regulations f the San Joaquin Local Health Di?trict. Home caner or license agent's signature certifies the following: "I certify that in ahe performance of the work for which this permit is issued, I shall not empl y any person in su h manner as t become le -tiS,workm8n's co sation laws of California." 6ontractor's hiring or sub-contracting signature certif es the following: " certify tin h an f the work for u4 ch t rmit is issued, I shall a ;ploy persons subject to workman's compensa- tionws of Galiforni The a plic c or all eq I Comp to drawin on Tse id — , . I��_//,�A� Signed Title: pate: OR DEQARTMENT USE ONLY Application Accepted by Date Area .�i -7 Pit or Grout Inspection by Data Final Inspection by DateAl-Z - S Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 1323-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.Q. Box 2009, Stk., CA 95201 FEECK INFO AMOUNT DUE '1 AMOUNT REMITTED ASH RECEIVED BY DATE PERMIT NO. r.EH 13-24 1REV.I/As) LOW EH 14-28