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APPLICATION huh rtnrvttt OC�SAN JOAQUIN LOCAL HEALTH DISTRICT �QF S1�k*1T 1601 E. HAZELTONAVE., STOCKTON, CA R Eff b �EP\A - Telephone (209) -- C P�1P�� _I�l� �OP�N `+` PERMIT EXPIRES 1 YEAR FROM DATE ISSUED OCT 2 5 oP��EN`�� (Complete in Triplicate) \ FNVIRONMEY'tC� TAI. q� PP R r t Irae�WQS) on is,.= oorr� y made to the San Joaquin Local Health District for a permit to construct and/or install the f the San Jo S a in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well.pump and the Local Health District) ` �J Job Address / r' J City S�.�j�'j/�,u(/ Lot Size PM r/ Owner's Name /eDCddress /r �!_✓ —�,�!!.rf/Q Phone �/1//+ . Gp f F/pec Address / 1 iv License No. Contractor ! f -!t` d Phone TYPE OF WELL/PUMP: NEW WEL61l WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLA�TIONSYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK ;7—,f SEWER LINES Zf— DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICAT O Industrial ❑ Open Bottom ❑ Manteca Oia. of Well Excavation �.S 7 Dia. of Well Casing ! C✓ ❑ Domestic/Private PrGravel Pack ❑ Tracy Type of Casing J Specifications f"l Public fA'Otherl,,"4 l+^ 71 Delta Depth of Grout Seal Type of Grout t ' I I Irrigation —Approx. D pt I I Eastern Surface Seal Installed by �/✓Rn WGEc,- _ Repair Work Done L] Type of Pump '.110.11 H.P. 1/7- State Work Done _ Well Destruction ❑ Well Diameter Sealing Material (top 50'1 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION 1 1 DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) _ Installation will serve: 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 Capacity. 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 Line � SEEPAGE PITS I I Depth Size _ _ Number SUMPS -I Distance to nearest: Well Foundation Property Line I DISPOSAL PONDS ❑ T I hereby certify that 1 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 Dihtrict. 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 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 must ca or all rfarr!n � . Complete drawing on re side. Signed X _ Title: ✓fes/ Date: - - _ FOR DEPARTMENT USE ONLY A it Application Accepted by Date�JI— —_—_ Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: �� hl!jCm k-N&'OL-AhFiAfrZzi ❑ � 1 Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-83 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AAMfMOUNT' v D�UE\ AMOUNT REMITTED A RECEIVED BY DATE PERMIYQO. w ER 13-241REV.11x5) fD,CJ � O o+ EN 1426