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T APPLICATION FOR PERMIT pEGg �[E SAN JOAQUIN LOCAL HEALTH DISTRICT P a �g8� 1601 E. HAZE T ON AVE., STOCKTON, CA EA�-�H Telephone (209) 466-6781. ENS P1 H PERMIT EXPIRES 1'YEAR FROM DATE ISSUEDSj p�N��S4RvCVS (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 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. I , Job Address Z•O � r IM VAR ZIW,_CC City �IZWAC �y',�/ T� 0Lot Size_ PM Owner's Name—ANEW—M Address �fyQ •�• /r� �� /!/� Phone 5.t I! �i1 Ax'�F �n 5�5ao C5! Contractor_.�XPIZat3 nrt ,�7YC." Address -5099 D 64� 4MVU License No. X 343 Phon WELL REPLACEMENT TYPE OF WELL/PUMP: ff w NEW WELL [7 DESTRUCTION El PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ -OTHER'O" DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. - PROP. LINE "FOUNDATIONS— -- .-AGRICULTURE WELL=- OTHER WELL-- . A'/� ."" ��:.PITS/SUMPS„�_Y "a. SZ_ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial CJ Op ❑ °en Bottom Manteca pia. of Well Excavation 7 Dia, of Well Casing ❑ Domestic/Private 1�f Gravel Pack ❑ Tracy Type of Casing K601 Type ASWi�'evao � f-I Public ❑ Other {Yl Delta Depth of Grout Seal -SO Type of Grout �✓�� _ 4""im—govZrop krl2t W pprox. Depth W Eastern Surface Seal Installed by AGLf7 gx T-r2W Repair Work Done ❑ Type of Pump H.P. State Work Dane_ Well Destruction E] Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') I TYPE OF SEPTIC WORK: NEW INSTALLATION Cl REPAIR/ADDITION l I DESTRUCTION i I (No septic system permitted if public sewei is available � in 200 feet.) Installation will serve: Residel�"ce_ Commercial_ ther Number of living units: Number of bedrooms = Character of soil to a depth of 3 feet: Y Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments . PKG. TREATMENT PLT. E07) � Method of Disposal i Distance nearest: Well Foundation Property Line i LEACHING LINE ❑ Ii & Length of lines Total length/size FILTER BED Dist`ance to nearest: Well F ndation Property Line SEEPAGE PITS I I Depth Size Number SUMPS L-I Dis ante to nearest: Well Foundation Property Lin DISPOSAL NDS "”` p [f - — .m _ 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." �I' The applicant must call for all re'1 " s s. Com drawing on reverse side. Signed X Title: Date: FOR DEPARTMENT USE ONLY l I Application Accepted by Date i r Area Pit or Grout Inspection by Date � .7 Final Inspection by Date Additional Comments: ❑ 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. Bax 2009, Stk., CA 95201 FEE INFO AMOUNTIkDUE AMO NT REMITTED CKCASHRECEIVED BY DATE PERMIT'NO. 4 14 + EH -24IriEV. /nsr OY3��r EH 14-26 II -