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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT PAYM1ErNT 1601 E. HAZELTN ON*AVE., STOCKTON, CA RECEIVE D Telephone (209) 466-6781 n PERMIT EXPIRES VYEAR FROM DATE ISSUED " ` ' � f t 9 8� (Complete in Triplicate) ' ENVIRONMENTAL HEALTH I� r Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein Rkli"145KV ation is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Ryles and Regulations of the San Joaquin Local Health District: At r }' w.a,l : _ ; ,•� 1. 'i Jab Address rA I, A � `',I ' City Itl Lot Size PM Owner's Name .4 Address-'' Phone Contractor IT S,1770 X Address RPhone �(f License No. TYPE OF WELL/PUMP: IF NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION Jy SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES �• k DISPOSAL FLD. PROP, LINE riFOUf116AT10N AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE ' --TYPE•OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia�of Well Excavation Dia. of Well Casing p.y ,� Domestic ❑ Gravel Pack ❑ Tracy Type of Casing Specifications [] Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation ----Approx. Depth ❑ Eastern SurfaceSeal Installed by Repair Work Done ° Type of Pump4 .- H.P. State Work Done Well Destruction ❑. Well Diameter Sealing Material (top 501 l Depthr t Filler Material (Below_50') TYPE OF SEPTIC'WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is O(1 available within 200 feet.) p Installation will serve: Residence .Commercial_ Other Number of living units: Number of bedrooms -NA,11"-A k 1'Q Character of soil to a depth of F3 feet:./ Water table depth SEPTIC TANK ❑ Type/Mfg. Capacity I No. Compartments PKG. TREATMENT PLT. ❑ ( Method of Disposal G } Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ 0.& Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEP,XGE PITS' '❑°Depth -t. '_'1 Size Number SUMPS El Distance to nearest: �� Well Foundation Property Line V DISPOSAL PONDS ❑ I hereby certify that I have prepared this;application'and thatihe 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 ofrthe 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." I T_ j i — � I The applicant m all for II required in ction : mplete drawing on reverse side. 1 4 Signed Title: t"�'` Date: t 3 f ., -9 FOR DEPARTMENT USE ONLY Application Accepted by t � � � k � 1 Date + Ar Pit or Grout Inspection y Date Aa Final Inspection`by - Date '- Additional Comments: I� 3i 4 ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return ail copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 1 k - FEE INFO 'AMOUNT DUE AMOUNT REMITTED C RECEIVED BY DATE PERMIT"NO.7 + EH 13-24(REV.iia 5) ? •� �. �� 2� �' EH 7426