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APPLICATION FOR PERMIT ' SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 io Id 2 $� PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) ENVIROMENTAL HEALTH F ERMIT/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. L� Job Address ell l �/�WV 5OSliN �ity 22416W Lot Size ��X �� PM 2 /� Owner's Name 441W101,'^d�CCe� 07's./��✓`Address /�5��5 f�oi✓ >os�F�✓ 'e/Phone `F 09 3s— 01 o Contractor s/ /1�7! l�itfC; Address ac�'� fl�� Z) License No. Phone 6�;71-Z 7 TYPE OF WELL/PUMP: NEW WELL i:R WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLP. PROP. LINE 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 0 Domestic/Private XKGravel Pack 2(Tracy Type of Casing p Uc Specifications / ❑ Public ❑ Other CJ Delta Depth of Grout Seal Type of Grout .-kin and V_1/-1;-y Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION I❑ (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: ater table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Dista to nearest: Well Fo ,tion Property Line LEACHING LINE No. & Length of lines Total length/s" FILTER BED ❑ Distance to nearest: ell Foundation operty Line S£ GE PITS E7 Depth Size Number LIMPS 7-1Dist ce to nearest: Well Foundati n 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 nlyst call fora inspections omplete drawing on reverse side. 4Signed Title: 94C4.1C aril P/�/` -,_-- Date: 10 ec D R N N LY Application Accepted by Date 1!J -S-j ,Ikrea Pit or Grout Inspec on nate� Final Inspection by Data Additional Comm ts: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P,O. Box 2009, Stk., CA 95201 FEE 1 INFO AMOUNT DUE AMOUNT REMITTED ASH RECEIVED BY DATE PERMIT"N4. + EH 13-24 iREV. /e 5) EH 14-26