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. APPLICATION FOR PERMIT 41(. i PINE SAN-d�AQUIN LOCAL HEALTH DISTRICT FEB Z O VIM E. HAZELTON AVE., STOCKTON, CA '�i Telephone 1209) 466-6781 I ENVIR+�NMENTALHE/�Rj� ,T EXPIRES 1'YEAR FROM DATE ISSUED 1 I PERMIT/SERVICE I (Complete in Triplicate) i 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. 1962 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. 4 �— I Q Jab Address 335-V k 7Trr`R— City�AM� Lot Size PM 1 � Owner's Name,?Ie �D 7ZL t Address-)z 2 3S2) :2�•9+Ael Ikxr f&d• Phone.56 0 "' Contractor�R-E'�ta 0 Address 6 -'v ' License No/4 7� Phone 66n' � TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ � SYSTEM REPAIR ❑ OTHER ❑ .DISTANCE TO NEAREST: SEPTIC TANK r SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS 1 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial-- ❑.Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Q Domestic/Private 11 Gravel Pack ❑ Tracy Type of Casing Specifications I' M Public ❑ Other r ❑ Delta Depth of Grout Seal Type of Grout I I Irrigation _Approx. DepYh I I Eastern Surface Seal Installed by - Repair Work Done LY Type of Pump H.P. �� State Work Done _ Well Destruction ❑ Will Diameter Sealing Material (top 50') _ - Depth Filler-Material-I8elow-504 I TYPE OF SEPTIC WORK' NEW INSTALLATION I REPAIR/ADDITION I I DESTRUCTION I I (No septid system permhted it public sewer is r available withio 200 feat) I Installation will serve: Residence— Commercial_ Other - Number of living units: Number of bedrooms - Q Character of soil to a depth of 3 feet: Water table depth ! SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments 7 e PKG. TREATMENT PLT.❑ t �t MetWd of Disposal Distance to nearest: Well Foundation Property_Line% j Y y LEACHING LINE ❑ No. & Length of lines ,I Total length/size ✓ FILTER BED ❑ Distance to nearest: Well. Foundation Property Limi I � y SEEPAGE PITS I I Depth Size: /, Number SUMPS 0 Distance to nearest: Well Foundation Property Lim O DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joequin county ordinances, state laws, and t rules and regulations of the San Joaquin Local Health District. iII 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 subcontracting 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 ct c fit 11 required inspections. Compl Ile drawing on reverse side. 7 )� � 89 Signed X �`s'Title: � ' Date: i !% / OR DEPARTMENT USE ONLY -7 ' Application Accepted by ea r'y/ / _ Date �` I� Ar /` Pit or Grout impaction by Date` Final Inspection by�� ✓ Dated Additional Comments: f ❑ Stk 498-6781 ❑ Lodi 369.3621 ❑ Manteca B23-7104 ❑ Tracy 835-6395 I Applicant- Return all codes to: Environmental Health Permll/Services 1901 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 ` . IFEEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMITNO. ♦.EHta.2401EV.r1•sr L7--eq0 90 �� EH Ix A f.•