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t � -1�CY �,� P APPLICATION FOR PERMIT 7 �ir SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA SAN JOAQUIN LOCAL HEALTH DISTRICT' a Telephone {209} 466 6781 ENVIRONMENTAL HEALTH DIVISION PERMIT EXPIRES TYEAR FROM DATE ISSUED SPECIAL PERMIT (Complete in Triplicate) r 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. ii I L City Sr`�'-' Lot Size PM Job Address�c�lC� n`4�4 I L � t C v7 �L��Gfc,.— Address G G �j s" G�7'"`� Phone Owner's Name Contractor �ie� u-✓ Address /z'er.ei License No. yy667� Phone 7~ X67 TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ o DISTANCE TO NEAREST: SEPTIC TANK 0— SEWER LINES Ca_} DISPOSAL FLD, PROP. LINE FOUNDATION 6-_— AGRICULTURE WELL OTHER WELL 7b PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA-..-.CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑"Manteca Dia. of Well Excavation s Dia. of Well Casing 7' t't ❑ Domestic/Private ravel Pack ❑ Tracy Type of Casing 4tlL Specifications F1 Public R Other 1A'. ❑ Delta Depth of Grout Seal r Type of Grout� f - I I Irrigation �:Ap rox. Depth l I Eastern Surface Seal Installed by /-,q y - re1k1 r Slate Work Done_ pair Work Done ❑ Type of Pump H•P• Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 50') - TYPE OF SEPTIC WORK: NEW INSTALLATION i-1 REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is ) I, available within 200 feet.) f�✓ Installation will serve: Residence I Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet:I �, SEPTIC TANK ❑ Type/Mfg Capacity N 3. Comport F q 1 r PKG. TREATMENT PLT. ❑ i1 HY Mull dor Disposal Distance'to nearest: Well Foundation Property Line n< LEACHING LINE ❑ No. & Length of lines To �'kLi"�hr/�iz � i FILTER BED ❑ Distance to nearest: " Well Foundation Property Line SEEPAGE PITS VI Depth Size Number i SUMPS L-I Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I 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." t The applicant must call for all required inspections. Complete drawing on reverse side. Signed X_�C..F+� v G / f Title: Date: 1 FOR DEPARTMENT USE ONLY l Application Accepted by Date ea JJ Date/ Pita Gra Inspection by Date ? � F• alpinspection by . 10 Additional Commens:l W y `t '�r ❑ 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 REMITTED H RECEIVED BY DATE PERMIT'ND. INFO + EH 13-241REV.riK51 EH 14-26 �r.�