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EaJOAQUIN APPLICATION FOR PERMIT �E ��* LOCAL HEALTH DISTRICT FEB 2 0 !,rs 1601 E. HAZELTON AVE., STOCKTON, CA ENVIRON��E�vTAL'-� Telephone (209) 466-6781 PER IT/SERV� 4 EXPIRES 1 YEAR FROM DATE ISSUED 'I (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.fz( � ..�Y�II>✓L�/Z.� 1�� ( S3 C2 Job Address -- P $� t7 City Lot Size PM i Owner's Name 6 ,'- AL33 Address / / Phone �+ I Contractor Address 4� �`�� License N% Z3 12 Phonez 1- i TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ 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 l L3"Industrial ❑ Open Bottom ❑ Manteca, Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications O f"1 Public 71 Other I ❑ Delta Depth of Grout Seal Type of Grout I I Irrigation —.Approx. Dept_b l l.Eastern I Surface Seal Installed by �_ r Repair Work Done C'T Type of Pum' H.P;. Q State Work Done Well Destruction ❑ Well Diameter Sealing Material Itop 501 ; Depth Filler Material (Below 50') — t� TYPE OF SEPTIC WORK: NEW INSTALLATION I1 REPAIR/ADDITION I I DESTRUCTION I I lNo septic system permitted if public sewer is t available within 200 feet.) Installation will serve: Residence_ Commercial Other i d , Number of living units: Number of bedrooms r II .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 �C r--� —Distance-to-nearest:- -Well - f- - -foundation Propi rty Line I _ I LEACHING LINE ❑ No. & Length of lines --'S- Total length/size I FILTER BED ❑ Distance to nearest: Well r —Foundation Property Line r i a SEEPAGE PITS I 1 Depth Size Number �r SUMPS ❑ Distance to nearest: Well "Foundation Property Line - DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that theiwork will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health Dotrict. r 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 i employ any person in such manner as to become subject to workman's compensation laws of California Contractor's hiring or sub-contracting signature iJ 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." Theapplicant mt call.ffoorlall'requir d inspections. Complete �d(rawing o reverse side. JJ Cif Signed X -" r '"'Title: Date: F DEPARTMENT USE ONLY �� Application Accepted by Date aG '�° Area I Pit or Grout Inspection by Date Final Inspection by Dated Zf l Additional Comments: 1 ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Mentece-�823-7104 ❑ Tracy 835-6385 i Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave-, P.O. Box 2009, Silk., CA 95201 FEE AMOUNT DUE; AMOUNT REMITTED CK ASH RECEIVED BY DATE PERMIT NO. INFO +.EH 13-24IREV.t/nsl CTC>-3 I EH 14-20 y p