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-- Ec APPLICATION FOR PERMIT71 SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA SEP 0 6 1` `"Elf0 Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ENVIRONMENTAL HEALTH (Complete in Triplicate) PERMIT/5J;RKES 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 welUpump and the Rules and Regulations of the San Joaquin Local Health District. � n Job Address . 011 F Av�yl z'v k't._ �_..._,__ City Lot Sire PM iOwner's Name Address Phone1 T ! I oU ntfactor License fVo. 15;O f Phone_fI /V f 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 PE pF WyELL PROBLEM AREA CONSTRUCT1pN SPECIFICATION-5`"'__'` �i ❑ Industrial Cl Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing estic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications M Public F1 Other I FlDelta Depth of Grout Seal Type of Grout I I Irrigation ___.Approx. f 3Dept I I Eastern purface Seal i tolled by Repair Work Done XType of Pump ` H.P. 1o�/� State Work Done Well Destruction ❑ Well DiameSealing Material (top 50') �1 Depth �'/ 7 Filler Material (BeIow 50') _ TYPE OF SEPTIC WORK: NEW INSTALLATION I:IL REPAIR/ADDITION f I - DESTRUCTION I I (No septic system permitted if public sewer is i —_...,�.e.....� . __ -�' . -'�-�.'.`�-=.� �-.. . ----available-within-200-#eet:-) , Installation will serve: Residence Commercial w OtherA 'l Number of living units: Number of bedrooms j Character of soil to a depth of 3 feet: IWater table depth SEPTIC TANK ❑ Type/Mfg t Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal i : i Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Length � Total length/size FILTER BED ❑ Distance to nearest: Well Foundation e Property Line SEEPAGE PITS I 1 Depth Size Number SUMPS ❑ Distance to nearest: Well "�. Foundation Property Line DISPOSAL_ PONDS ❑ tit 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 Di%trict. 1- 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 applican st call r a re uired inspections. Complete drawing on re se side. I �f Signa Till Date: FO DEPARTMENT USE ONLY Application Accepted by - Date � ATea Pit or Grout Inspection by Date Final Inspection by Date l F© k Additional Comments: i ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy &35-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED GASH RECEIVED BY DATE PERMIT NO. +.EH 13-241REV.iiMsy ��lq-o Q— EFIlIj91I 14-28