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APPLICATION FOR PERMIT SAN JOAO,UIN LOCAL HEALTH DISTRICT 'I 1601 J E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 i PERMIT;EXPIRES 1 YEAR FROM DATE ISSUED 1, (Complete'in,Triplicate) 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 _ ©QTl rco 1 n h City Lot Size �42q,g 13PM yj� f F Owner's Name 3 _ Address Z'S G r `l u)u `2o Phone ass-Sag I Contractor Address 135--6 -� License No.21UM3 Phone 606 e5- TYPE TYPE OF WELL/PUMP:,J NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ i PUMP INSTALLATION O f SYSTEM REPAIR ❑ OTHER ❑ j DISTANCE TO NEAREST: SEPTIC TANK _-,__...� SEWER LINES DISPOSAL FLD. rra r POOP. LINE ` FOUNDATION S AGRICULTURE WELL ya{ OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA -,CONSTRUCTION SPECIFICATIONS 11 El Industrial Ll Open Bottom 11 Manteca Dia. of Well Excavation Dia. of Well Casing Cts Ea. Domestic/Private .Gravel Pack ❑Tracy Type of Casing PVC, SM UOSpecifications Ll ❑ Other , k I` ❑ Pelta Depth of Grout Seal -�� _ Type of Grout � _ � p El Irrigation �5�pprox. Depth 13 Eastern Surface Seal Installed by ___ j Repair Work Done ❑ Type of Pu Q P. .mak State Work Done_ l Well Destruction ❑ Well Diameter I�, Sealing Material (top 501 9 Depth I� Filler Material (Below 501 TYPE OF-SEPTIC WORK: NEW INSTALLATION Q;` REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is s 0 available within 200 feet.) i Installation will serve: Residence— Commercial_ Other Number of living units: Number of bedrooms Character oflsoil to a depth of 3 feet: .II Water table depth SEPTIC TANK ❑ Type/Mfg l0 Capacity No. Compartments i PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well - Foundation Property Line LEACHING LINE ❑ No. 8 Length of lines Total length/size FILTER BED ❑ Distance to nearest: I Well Foundation Property Line I SEEPAGE'PITS ❑ Depth Size Number P a SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS Cl 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 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 fy that int performance of the work for which this permit`is issued,I shall employ persons subject to workman's compensa- tion laws of Cal'or The,applicant for all req r t plete drawing on reverse side. # - �f/JV&In Date: G Signed `� TiTitle: ; �JF R DEPARTMENT USE ONLY ti Date f-Z2-9'7 Area lr I� Application Accepts by� � Pit or Grp Inspe : by Date��Final Inspection by Date N14 Additional Comments: v � � I� �, u _ w r � •` ❑ Stk 466-6781 © Lodi 369-3621 antece 823-7104 ❑ Tracy 835-6385 j Applicant- Return all copies to: Environmental Health Permit/Services 1601.E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 I.. � FEE AMOUNT DUE AMOUNT REMITTED CA RECEIVED BY DATE PERMIT NO. INFO +,-EH 13-24.1REV.i/a5) EH 1428 l �i•� C) L LO O ! U 7�12.E _ I I� ,