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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZETON AVE., STOCKTON, CA Telephone (209j"k"COU--N-PUBLIC HEALTH SERVIGBS PERMIT EXPIRES 1 YEAR FRO JyMOMMIt r"LHEALTHDIVISION (Complete in Triplicate)SPECIAL PERMIT 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 S—A-4 "'�b ; T0.T ��1�� City Lot Size PM Owner's Name ILIA--h Crre34o Address I1392- WR5.¢ �.cvc:rw�e+rba •jt}Or�'3►}�3+►�-3 Contractor -T'��e Address '{�I dVo[ �>!"� Sint License No. Phan - h 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 S' AGRICULTURE WELL OTHER WELL PITS/SUMPS Q� INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS X Industrial ❑ Open Bottom B Manteca Dia. of Well Excavation Dia. of Well Casing �- ❑ Domestic I Private L Gravel Pack ❑ Tracy Type of Casing Cur6w Specifications + b.gn`4+eFtr fie/ I-I PublicCl Other F1Delta Depth of Grout Seal _7 2- Type of Grout .L4kry t.�n,�_ I I Irrigation ybtApprox. Depth I I Eastern Surface Seal Installed byTEkyh%P_ &rbk& _ Repair Work Done ❑ Type of Pump H.P, State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material 18elow 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I1 REPAIR/ADDITION I I DESTRUCTION E I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other 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 I I Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 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 Di§trict. 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 inspections. Complete drawing on reverse side. "A,Signed X ., R� _- Title: f by Date: FUR PARTMIENT USE ONLY �/ Application Accepted byZA ' C t-3""""" Date S Area T5 Pit or Grout Inspection by JT\,r.�c�� _ / Date Final Inspection by ,G��-c I�(I1� DateC21� r ti Additional Comments: fit/ PL ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Mant a' 823-7104 ❑ Tra4 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE K 0 INFO AMOUNT DUE AMOUNT REMITTED CASN RECEIVED BY DATE PERMIT'NO. + EN 13-21IREV.r/x51 f- aO 75 °Q 3� 1l 5��d a�37 EH 14-2626 JJ I `'