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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT i 1601 E. HAZEL T ON AVE., STOCKTON, CA ��Y�E�� Telephone (209) 466-6781 RECEIVED PERMIT EXPIRES 'I YEAR FROM DATE ISSUED mi R 13 0 1190 (Complete in Triplicate) SAS' J0ik!1-�." ; f."I'TY Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the�is,�re'>�nc�ibed'.'Tttir�fa�{a�lication is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and tEl�lfj'A `�11 �111a4i�ii: olilllOQslaquin Local Health District. Job Address `��4 Liloi Y.0�h �r City r<(1]` � TO14 Lot Size PM :14 QC t4l Z ?z17_9 I o f Owner's Name eA Il- QY Address Phone Contract '� WCl Addres0gO S905.7,6W ��icense No.SZI e��_ Phone �4 � TYPE OF WELL/PUMP: i[ NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION EV SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO-NEAREST: SEPTIC TANK – -SEWER LINES DISPOSAL FLD. . -P_ROP..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 ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ¢: F1 Public F]Iother F1Delta Depth of Grout Seal Type of Grout _ I•I irrigation �1Ip--Approx. De th t I Eastern S rface Seal Installed by Repair Work Done (11", Type of Pump H.P, State Work Done Pump �� G[CQfC Well Destruction ❑ W'll Diameter 4 rI Sealing Material (top 50'1 O Depth {s Filler Material I Below 50'I —_ TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is Iavailable within 200 feet.) Installation will serve: Residence_ Commercial— Other Number of living units: _JL Number of bedrooms j Character of soil to a dept of 3 feet: Water table depth SEPTIC TANK ❑ :Type/Mfg Capacity No. Compartments i 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 t SEEPAGE PITS l I J.Depth Size Number SUMPS r Ll Distance to nearest: Well T Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that I have prIepared 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." 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." r�J The applicant call for all re fired i spections. Complete drawing on reverse side. Q, Signed X � Title: _ Date: -I 1 0 F. R DEPARTMENT USE ONLY Application Accepted b11'y ' date "' ^ O ~ Area l Pit or Grout Inspection by Date Final Inspection by Date 5--ZAi Additional Comments: C1 Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT'NO. INFO CASH p r .-M13-241REV.,r/n5) I EH 14-2e LJ