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� APPLICATION FOR PERMIT LA AN JOAQUIN LOCAL HEALTH DISTR16T 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 EIyVIROMENTA� HFAMMIT EXPIRES 1'YEAR FROM DATE ISSUED FERMI_[/SERVICES (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. Job Address /�Q 7 �/. /` 7 City X25,_ Lot Size PM Owner's Name /��'0[.�T+�Q'� �t�dddress J/ V�� 27, Ph. g Phone u Q/J Contractor �� •�AddressCCll� V ^ w- 4- t� License No& 2-373 Phom ��'tXJ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK _SEWER LINES DISPOSAL FLD. 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 UVDomestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications F1 Public Ll Other ❑ Delta Depth of Grout Seal Type of Grout_ I 1 Irrigation —Approx. Depth# I I Eastern _Surface S I Installed by _ Repair Work Done 0' Type of Pump H.P. / a, State Work Done r Well Destruction ❑ Well Diameter - Sealing Material (top 501 Depth Filler Material (Below:501 TYPE OF SEPTIC WORK: NEW INSTALLATION I:1 REPAIR/ADDITION 1 I -ESTRUCTION I I INo septic system permitted if public sewer is available within 200 feel) Installation will sero:: Residence_ Commercial_ Other Number of living units: _ Number of bedrooms ' Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Papacity - No. Compartments PKG. TREATMENT PLT.❑ Method of Disposal Distance to nearest: Well - -- - Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Lim SEEPAGE PITS I I Depth Size Number SUMPS Ll Distance to nearest: Well Foundation 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."Contractors 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." The applicaust ll for 11 requi d inspections. Completey��drrayawing on�reverse e side. Signed X wlFida: V Date: O ^ O 00 FO� PARTMENT USE ONLY Application Accepted byy a Date 6 Area� Pi[or Grout Inspection by Date Final Inspection by O Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 83546385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AM UNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. ♦.EH 1124(REV.1/x51 Com- ,E��Y'Y NO EH rola ..J Tl l/�