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Y; APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT BAR I b i 1601 E. HAZE TONtlAVE., STOCKTON, CA Telephone 12091 466-6* ENVIRpMENTAL HEALTH PERMIT EXPIRES VYEAR FROWDATE 'ISSUED PERMIT/SERVICES (Complete'in jriplicate) 10 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 Ryles and Regulations of the San Joaquin Local Health District. t7 Job Address fe ^E City Lot Size PM Owner's Name - Address 110904 AEF Phone 2 10 Contractor Add ressfl77--`/lY�-, .L License No. .5226 Phone 9—Z TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEM T ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER. DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL`FLD. PROP.-LINE Q FOUNDATION 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 Z Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing i4,Specifications ❑ Public ❑ Other ❑ Delta . Depth of Grout Seal ".Type of Grout ❑ Irrigation --Approx. De th ❑ Eastern Surface Seal Installed by 41' Repair Work Done ,lJ Type of Pump �._� H.P. - State Work Pone p Well Destruction ❑ Well Diameter Sealing Material Itop 501,�r ' Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ Mo septic system permitted if public sewer is available within.200 feet.) Installation will serve: Residence_ Commercial_ Other y 1 Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: -- � s Water table depth SEPTIC TANK ❑ Type/Mfg Capacity�� No. Compartments t PKG. TREATMENT PLT. ❑ _T Method of Disposal Distance to nearest: Well ��- Foundatidn Property Line LEACHING LINE ❑ No. & Lenth of lines Length i Total length/size r� FILTER BED ❑ Distance to nearest: Well -F'Koundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ .Distance to nearest:__ Well ,Foundation Property Line DISPOSAL PONDS ❑ 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, I shall employ persons subject to workman's compensa- tion laws of California." The applicant m t call f aNrequired inspections. Complete drawing on verse side. Signed X J Title: lU Date: z FOR DEPARTMENT USE ONLY s Application Accepted by \0 % Date ,S_1% � Arreea p Pit or Grout Inspection !i� Date -Final Inspection by, moi" Date 222 Additional Comments: . ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6M Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk.,, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. * EH13-241REV.t/55) J� � _ �, EH 14-26 t