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EG "EI APPLICATION FOR PERMIT ' _& SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA NOV 1 4,989 Telephone (209) 466-6781 ENVIRONMENTAL HEATH PERMIT EXPIRES 1 YEAR FROM DATE ISSUED PERM IT/SER%:, E;3 (Complete in Triplicate) 4 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. ,, / Job Address _�� ( / ,�jL.74&/ City ,5741C Lot sizePM / Owner's Name /°1 r'�/��✓,fi :✓� Address _,.( /'U �(I!/'�Phone v SPECTFLu C2 -0 Contractor EXPI0rct'%0ft tvvc.. Address_5- [.fc-f-oln C %- 1S_20TLicense No. SL Z2Ceg Phone yds B�12" TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER .S<v / bCrrw✓.-; DISTANCE TO NEAREST: SEPTIC TANK 46e' y SEWER LINES DISPOSAL FLD. PROP. LINE. FOUNDATION AGRICULTURE WELL ' OTHER WELL PITS/SUMPS ILL' b INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS _ ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation t Dia. of Well Casing 'kfL r'j ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing ,/�/1['_j'rr�� Specifications I'1 Public �4 Other FI Delta Depth of Grout Seal Z7.Ti Type of Grout I I Iniyation 4&'Approx. Depth I I Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump H.P. State Work Done _,A161,) -9 0. e Well Destruction ❑ Well Diameter _-d� Sealing Material (top 501 J SAr> rr ��ra7t �tlCr� Depth Filler Material (Below 50') —_ O TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION f I DESTRUCTION 1 I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other 6 Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments y, PKG. TREATMENT PLT.❑ Method of Disposal Distance to nearest: Well Foundation Property Line 4 LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line GG SEEPAGE PITS I I Depth Size Number ` SUMPS _1 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that 1 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 Di3trict. 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 Cali ia." this The applica mu t call for It re wired pe 'ons. Complete drawing on reverse side. /// Signed X Title: Y L— ' Date: • ( —2--V7 FO EPA T NT USE ONLY Application Accepted by v _��LJ - Date Pit or Grout Inspection by Date Final Inspection byi�' - y Date, 4 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. Box 2009, Stk., CA 95201 6. FEE AMOUNT DUE NAMOUNT REMITTED RECEIVED BY DATE PERMIT-NO.. FO �. EH 11324 IREV.liN 5) �45sq EH