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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT D �� } 1601 E. HAZELTON AVE., STOCKTON, CA �+ 1 Telephone (209) 466-6781 SEP 2 3 $ PERMIT EXPIRES 1"YEAR FROM DATE ISSUED `. (Complete in Triplicate) ENVIRONMENTAL HEALTH WIT g ��''FFrr Application is haieby made to the San Joaquin Local Health District for a permit to Construct and/or install the work herein de�ci?rbiihis 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 AddressJZ.Z/ c ,2& _ City +�L��t� Lot Size PM Owner's Name �T' JGJiP.fI �� /' Address o aZG! Phone . Ef ContractorGff�iV Address All a Lc/ License No2A Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEME T ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR El OTHER ❑ F DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL -PITS/SUMPS r INTENDED USE TYPE OF-WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑�� Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing juomestic/Private ❑ Gravel Pack ❑ Tracy Type of.Casing Specifications 171 Public Cl Other El Delta Depth of Grout Seal Type of Grout I I Irrigation _.-Approx. Depth I I Eastern Surface'Seal Installed by Repair Work Done ❑ Type of Pump t ugh H.P, � Z�lf/,® State Work Done_ Well Destruction ElWell Diameter r--G// Sealing Material (top 50') Depth 4 -,21 Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION I I {DESTRUCTION i I (No septic system permitted if public sewer is available within 200 feet.l Installation will serve: Residence_ 'Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: t Water table depth SEPTIC TANK ❑ Type/Mfiig Capacity No. Compartments PKG. TREATMENT PLT. LI1 Method of Disposal l Distanceto nearest: Well Foundation Property Line t f1 LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line It �I I SEEPAGE PITS I I Depth iI -' --Size t _ Number SUMPS 0 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 bf 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 certifies the following: "I certify that in the'perforrnande' of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." ` The applicant mu all for all red inspection Complete drawing on reverse side. w Sign Title �SIYJ�.�/ r/ Date: FOR DEPARTMENT USE ONLY (1_ 'Q Application Accepted by 'i Date 6 —`' U Area Pit or Grout Inspection by Data Final Inspection by Awl Date Additional Comments: f ; ❑ 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 1 CKO INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT"NO. +.EH13-24 kREV. /n51 EH 14-2a