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Y✓` APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT I 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 SEP 2 6 1o"? f TH MEt�� PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ENVIRONMENTA III i (Complete in Triplicate) PERMIT/SERVICES 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. --, yy Job Address d + sC.V"' City Lot Size PM Owner's Name 4 Address — Phone Z , r . S-. r � a7 Contractor Address �J (License No.y�3`3�CZ Phon TYPE OF WELL/PUMP: NEW WELL 0`'r , .'� WELL REPLACEMENT EDDESTRUCTION ❑ PUMP INSTALLATION (9� SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP, LINE FOUNDATION AGRICULTURE WELL wOTHER W _ ELL' .. INTENDED USE TYPE OF WELL PROBLEM-AREA CONSTRUCTION SPECIFICATIONS ❑Z1 du rial LJ Open Bottom LJ Manteca Dia. of Well Excavation Dia. of Well Casing omestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications M Public D Other I Fl Delta Depth of Grout Seal Type of Grout _ a 1 1 Irrigation --Approx. Depth l 1 EasternSurface Seal Installed by Repair Work Done L-1Type of Pump. H,P. .j�-�f State Work Done Well Destruction ❑ Well Diameter*� ' Sealing Material (top 50') Depth Filler Material (Below 50'I TYPE OF 14 SEPTIC WORK: NEW INSTALLATION I] REPAIR/ADDITION I I DESTRUCTION I I (No septic,system permitted it public sewer is r rihin 200 feet.)w available Installation will serve: Residence— Commercial_ Other a--le Number of living units: Number of bedrooms i I, Character of sail to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity - No?Compartments ` PKG. TREATMENT PLT. 11 -r—Method of Disposal t Distance to nearest: Well Foundation... . _Property Line ' LEACHING LINE ❑ No. & Lengt i of lines Total length/size ] ,FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I 1 Depth Size Number -. - .SUMPS# Distance to nearest: Well° foundation - Property Line DISPOSAL PONDS ❑ 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. „ f 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: 1 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 it require ictions. Complete drawing on verse side. ! Signed X Title: .7 - 0 — R l � '��!! �i Date: i# R DEPARTMENT USE ONLYp I Application Accepted by _ Aoo;`� ,_ ,�, _ Date � /v �'f" Area I Pit or Grout Inspection by Date Final Inspection by Date «1. ' �d i .. I,Additions! Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 i i Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk-, CA 95201At FEE CK 0 , �+ INFO AMOUNT DUE AMOUNT F(EMITTEb G SH RECEIVED BY GATE PERMIT'NO. tEH13-24IREV.t/.n sl ©�� ' EH 14-28TpAis a- 0