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;�Tq ` Cs, �yg 14 APPLICATION FOR PERMIT t]1.l AN JOAQUIN LOCAL HEALTH DISTRICT AS 1601 E. HAZELFON AVE., STOCKTON, CA SF Telephone (209) 466-6781 EtvVIROMEhTAI" HEp�RM1T EXPIRES 1 YEAR FROM DATE ISSUED SERVICES (Complete in Triplicate) FERMIYI5 r. 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 /Z )I�17�fm '�I /yt,T�te'�'-�--*',,� / City _ Lot Size PM Owner's Name ^`'C_�"oD��'^'^`''�A / /A(cddress &U('2G 27,�y/?g �(rAu Phone U 6 �/� Contractor `��"'�' ��`"%`'' Address 1`� R C - � "—^ License No�� 2'323 Phone/- -g4 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ \ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ \ r DISTANCE TO NEAREST: SEPTIC TANK - ..SEWER LINES DISPOSAL FLD. PROP. LINE Q FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS + \ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS V ❑ Industrial ❑ Opan Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing UPDomestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 1-1 Public ❑ Other El Delta Depth of Grout Seal Type of Grout_ r I I Irrigation __Approx. Depthho I I�Eaastern �5 ace S I Insta)led by _ Repair Work Done L3 Type of Pump �^w ' H.P. / State Work Done_ Well Destruction ❑ Well Diameter Sealing Material Atop 50') _ Depth Filler Material(Below.501 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I 1 (No septic system permitted if public sewer is -" available within 200 feet.) Installation will serve: Residence— Commercial— Other r. Number of living units: _ Number of bedrooms - - Character of sol to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Fapacity No. Compartments ` PKG. TREATMENT PLT. ❑ - - Method of Disposal Distance to nearest: - -Welf " Foundation Property Line LEACHING LINE ❑ No. 8 Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number a„ SUMPS ❑ 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 Di1trict. r 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 lawsi.of California."Contractoes 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 applicca at II for 11 requi d inspections. Complete yy drawing o�n reverse_side. /�l�Ti Signed X tie: /�V Date: FO(ZXR PARTMENT USE ONLY `. Application Accepted by fz v L Date Area 0,/, PR or Grout inspection y -- _ Date Finel Inspection by > -- Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca B23-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE NFO AMOUNT DUE AM UNT REMITTED CASH CK I RECEIVED BY DATE PERMIT'NO. EH 1}24 IREV.1 rn51 EH 14N