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APPLICATION;FOR.PERMIT ° SAN JOAQUIN LOCAL HEALTH DISTRICT f;4b p, +.t 7-4/-6;- 1601 -//-8;1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 _ PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate.). -o 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 Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin made in compliance with San Local Health District. ±r 3,� f �L �� ,City 7�flCTt Size - PM Job Address --R-3z ✓ �/�� (a�7'�� !'¢ Address Phone .- Owner's Name j Qty/ Phone Contractor's Name vY ° y C License No. TYPE OF WELL/PUMP: I� NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ t PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER E3 € DISTANCE TO NEAREST: SEPTIC TANK SEWER.LINES_ _. _. -. _DISPOSAL-FLD_. PROP. LINE 3` ,AGRICULTURE WELL OTHER WELL PITS/SUMPS FOUNDATION - INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ' Dia. of Well Casing ❑ Industrial 0 Open Bottom LDMantecDia. of Well Excavation a Specifications ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing,° - ❑ Public ❑ Other ❑ Delta Depth of Grout Seai ` '} Type of Grout r ❑ Irrigation pprox. Depth ❑ Eastern Surface Seal Installed by Repair Work Done 11 Type,of Pump ? H.P. State Work Done Well Destruction ❑ Well Diameter Sealing,Material (top 50'1 Depth Filler/Material (Below 50') TYPE OF SEPTIC WORK: NEIN INSTAL A ION ❑ REPAIR/ADDITION4 ESTRUCTiON vaNaailable-wthin 200 feet.)- if public sewer is 1. /� r Installation will—serve:—Resid1 illserve:—Residl nce LSC mmerci l ✓� Other Number of livirig-units: _� Number of bedrooms ,l Water table depth Character of soil to a depth of 3 feet: � -T— E ♦ .�— i Z!1 No. Compartments SEPTIC TANK a ��ype/Mfg ('tY.u'f Capac , E{ ^� Method of Disposal PKG. TREATMENT PLT. ❑ I �— /, �� . f�' Property Line Z ' t Distance to nearest: Well Foundation , LEACHING LINE pfr, f ElNo. & Length of lines • Total length/size L- ?i' Lance to nearest: Well Foundation Property Line ' ' FILTER BED�y�f 1, 1 - - " Number SEEPAGE PITS/ [�` Depth Size SUMPS Sl - ` istance to nearest: Well Foundation Property Line DISPOSAL POND II' I hereby certify than 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 persokin such manner as to become subject to workman's compensation laws of California., Contractor's 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." . IIII The applicant must I r all�requir ins pe Complete drawing on reverse side. i I Title: Date: ' Signed R __T FOR DEPARTMENT USE.ONLYIRS ^ rArea fy - k Ap ' anDate on Accepted by h r-- -7 I � � � Date,.L� �! (�)oGrout Inspection by Date Fin Inspection by ' Additional Comments: \Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca -7104 ❑ Tracy 8355-6385 rAWficant- Return all copiesgto: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 1 I� ffEE[=T RECEIVED BY DATE PERMIT N0. SH f q + EH 1&24(REV.10183) + 1 S EH 14-28 -i