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- & '�' r .fAPPLICATION FOR PERMIT r .;,•SAN OJ (JIN LOCAL HEALTH DISTRICT FEB 2 U 112nT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 ENVIRUPVI'JiENTAL HEWW'AIT EXPIRES 1 YEAR FROM DATE ISSUED PERMIT/SERVICE (Complete in Triplicate) T 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 I made in compliance with San Joaquin County Ordinance No.549 for server or No. 1862 for well/Dump and the Rules and Regulations of the San Joaquin l Local Health Distnict. l T Job Address_? 33-- T&?ISL- City L Lot Size PM Owner's Name ¢�-�s--e- 7'�[./i�a� Address.0�Zt 3/ �7 7+�rkk�j Phone �/"'/Q n. �Jr-ry ��6 .d •c+.Grd� License No%Z31� Phone Tho 4' Contractor Address TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION O PUMP INSTALLATION ❑� SYSTEM REPAIR ❑ OTHER O DISTANCE TO NEAREST: SEPTIC TANK T SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENOW USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS r 7 ❑ Industrial-- T ❑Open Bottom ❑ Manteca Dia. of Well Excavation i Dia. of Well Casing Q Domestic/Private ❑Gravel Pack ❑ Tracy Type of Casing Specifications I'I Public ❑Other f ❑ Delta Depth of Grout Seal Type of Grout_ I I Irrigation _Approx. Depirit I I Eastern Surface Seal Installed by _ T Repair Work Done Lr Type of Pump H.P. 4-' State Work Done Well Destruction E3 Well Diameter Sealing Material (top 50') - _ ----.Cxpth �filler-Material-I Below-50:1 - - TYPE OF SEPTIC WORK: NEW INSTALLATION I REPAIR/ADDITION I I DESTRUCTION I I INo septictsyslem permitted if public sewer is I r available within 200 feet.) I Installation will serve: Residence_ Commercial_ Other ( - Number of living units: _ Number of bedrooms I 1 Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments J r PKC. TREATMENT PLT.❑ Metl>5rtl of Disposal / Distance to nearest: Well ~ Foundation Property.Linez 1 LEACHING LINE D No. 8 Length of lines Total length/sin . '1 FILTER BED ❑ Distance to nearest: Wei • Foundation Property UrtS SEEPAGE PITS I I Depth Siwe' t Number SUMPS ❑ Distance to neatest: Well Foundation Property Line O 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 Dr3trict. I `1 Home owner or licensed agents signature certifies the following: "1 certify that in the performance of the work for which this permit is issued, 1 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 { r The applicant/p st It for II required inspections. Complete drawing an reverse side. i 1 Signed X ( r All-Title: 24n— I Date: OR DEPARTMENT USE ONLY Application Accepted by rim•/- Date -2 Area l_ Pit or Grout Inspection by Dili Final Inspection by_7T__4 ODate Additional Comments: ' ❑ Stk 4666781 ❑ Lodi 3693621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave.. P.O. Box 2009, Silk., CA 95201 X FEE AMOUNT DUEAMOUNT REMITTED CASH RECEIVED BY DATE PERMITNO. INFO ..ER 1344 tREY.11.51 EH to-2e 1- y