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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICJAN IOAQUIN LOCAL HEALTH DISTRICT1601 E. HAZELTON AVE., STOCKTON, CA N��RONMLNTAL HEALTH DIVISION Telephone (209) 466-6781 SPECIAL PERMIT ,I PERMIT EXPIRES 1YEAR FROM DATE ISSUED (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 appl 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 ication is Local Health District. E G K41' r UftEsc flvc. jt— r Job Address t�Mr/1 W� (,✓.` [� City G ckbn' Lot Size PM M Owner's Name O T t k/Z., Gt y J Address _ Phone qq2- Contractor. O x� r�'cws/� Address Z 3 Al-%.i �A/ c d License No. yyLC7U Phone 537- 17L7 TYPE OF WELL/PUMP: NEW WELL WELL. REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST. SEPTIC TANK '-` SEWER LINES 4-Cd �p DISPOSAL FLD. PROP. LINE FOUNDATION :> t: AGRICULTURE WELL ' OTHER WELL t PITS/SUMPS i INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ industrial ❑ Open Bottom Manteca Dia. of Well Excavation %+ F ❑ Domestic/Private [Gravel Pack_ Dia. of Well Casing "Z ❑ Tracy Type of Casing Y G. 1`1 Public Specifications n Other. Cl Delta Depth of Grout Seal 8 I I Irrigation J Type of Grout i�r N4l�n74rNV _Approx. Depth I 1 Eastern Surface Seal Installed by k trepan ork Done ❑ Type of Pump H p State Work Dane_ Weli Destruction ❑ Well Diameter Sealing Material Itop 501 Depth # Filler Material (Below 50'I TYPE OF SEPTIC WORK: NEW INSTALLATION IT REPAIR/ADDITION I I DESTRUCTION i I (No septic ystem permitted if public sewer is w Installation will serve:--Residence_ :Commercial_ Other available . in 200 feet.) I Number of living units: Number of bedrooms 1 Character of soil to a depth of 3 feet: I SEPTIC TANKWater table depth ❑ 'Type/Mfg i Capacity p. j PKG. TREATMENT PLT. ❑ Compartmentsr ' �oti v al Distance to nearest: WellFoundation f ! - � ro y Dine LEACHING LINE ❑ No. & Length of lines v ' FILTER BEDTotal length ❑ Distance to'nearest: Well Foundation r _ « �—�Properly Line `-'pry'='rry�;•��, , SEEPAGE PITS I 1 Depth Size Number r ! "i i yr .� � Li1'1 SUMPS Ll Distance to nearest: WellfJ' Foundation Property Line DISPOSAL PONDS ❑ 4. 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, f shall employ persons subject to workman's compensa- tion laws of California." The applicant must Cali for all required inspections,q I>ections. Complete drawing on reverse side. Signed X G Title: Date: �r1 FOR ARTMENT USE ONLY Application Accepted by Date re Pit or Grout inspection by Date ,� Final Inspection by �Date�Z—:�� Additional Comments: „l ❑ Stk 466-6781 ❑ Lodi 369-3621 ' _ CI Manteca 823-7104 Applicant - Return all copies to: EnWonmental Health Permit/Services 1601 E.❑Hazelton Tracy 3Ave., P O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT UE AMOUNT REMITTED RECEIVED BY DATE PERMIT'NO. + EH 13-24(REV.iin5) EH 1428