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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (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. p f ` Job Add tf s �� h.I� City �ot SizeChAs. 6244V,77 �`'�n4t C9ZePM Owner's Name 4 FE Tl,[.E ��'/ YlC%�Adiare�ss �f11/1 lssa 2265 -7 Phone Contractor AaAddress a7/,may!moi .�> License No. Phone TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATIONk, SYSTEM REPAIR ❑ OTHEp ❑ N DISTANCE TO NEAREST: SEPTIC TANK 7 SEWER LINES DISPOSAL FLD. 7t6PROP. LINE J/Gl FOUNDATION �tr)_— AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATI NS / /�/rGC industrial ❑ Open Bottom ❑ Manteca Dia- of Well Excavation: Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of CasingSS�t Specfications--/[_6 V ❑ Public L3 Other [3 Delta Depth of Grout Seal /L" Type of Grout Adn ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump --51,A. H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 2D0 feet.) Installation will serve: Residence_ Commercial_ Other VV� r Q � Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth K� SEPTIC TANK ElType/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line y LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line v SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 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."Contractors 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 mu al requir tions. Complete drawing on�re/`��rs/e//J,'(de. /,-r��/ Signed X Gf ��'I Title: c Date: �► FOR DEPARTMENT USE ONLY yr., t1� Application Accepted by _ Date " �'— Area t�-� { ` Pit or Grout Inspection Date f� Final Inspection by �` rf Date r Additional Comments: / ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑Tracy 835638.5 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2008, Stk., CA 96201 r FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED eY DATE PERMIT.NO. `. EH 12-24 IREV.1/8 sl !?�[^ ✓ ."7�w / /� � -��, EH 1: