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APPLICATION FOR PERMIT 4 SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA 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 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 ��3 2- 4 �rCitY Lot Size Owner's Name -ah /0 4 � 5 Phone I~PMb d,r-� Contractor Q4 Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Ll DESTRUCTION ❑ PUMP INSLLATION L01 �.. _ SYSTEMREPAIRLI + OTHER ❑ 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 t ❑ Industrial ❑ Open Bottom ❑ Manteca Dia:of.Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other Cl Delta Depth of Grout Seal { Type of Grout I I Irrigation _.-Approx. Depth i I Eastern Surface Seal Installed by t f� Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50'1 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I1 REPAIR/ADDITION I I DESTRUCTION1i(T {No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial_-__ Other M I 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 FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS { l Depth Size Number SUMPS Cl Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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 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 California." The applicant must call for all required ins ctions. Complete drawing on reverse side. / Title: A5igned f�� Date: FOR DEPARTMENT USE ONLY Application Accepted by Date Area 0 Pit or Grout Inspectio 1 / Date 1) Final Inspection by Date Additional Comm �� ikrzY t�'OE� ! 1,./e lr1,l ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all rco pies to:� -EnA Environmental �it/Services Hazelton Ave., P.O. Box 2009, Stk., CA 95201 , (9AL cef�L Cl�!!�j -Sy lMFO MOUNT DUE AMOUNT REMITTED ��H///??? RECEIVED BY DATE PERMIT NO.�y + EH t3-24 ISM I/R5) C.-y -7 -r 11 t-�J' p I, 'J -S� V EH 114 26V / r `] -11