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APPLICATION FOR PERMIT SAN JOAQUIN.LOCAL HEALTH DISTRICT ,p .1601 E.. HAZEL T ON AVE., STOCKTON, CA a ffa l� `Telephone (209) 466-6781 PERMIT EXPIRES 'I YEAR FROM DATE ISSU�AN JOAQUIN LOCAL HEALTH DISTRI I, (Complete in Triplicate) ��ENVIROQNpME(N�TAALLHEEALTH ,DIIVISIOh Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work he�lll �EFRfeD�rtSs pica o,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 44[1 Wf'liartc WayCity StOCk Lot Size PM . 'Texaco 'RefiT,n address Phone Owner's Nam916-361-0614 cck. l'/i• 37,2•17 I Contractor Sierra Pacific Address License No. Phone – – TYPE OF WELL/PUMP: NEW WELL ? WELL REPLACEMENT ❑ ' DESTRUCTION ❑ SOIL fZ¢ V-Yr5 lt44 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHERX,'�— 1L DISTANCE TO NEAREST: .SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE l FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation a .25?1 Dia. of Well Casing rr ❑ Domestic/Private JGravel Pack ❑ Tracy Type of Casin Specifications } M Public ❑ Otherl Delta Depth of Grout.Seal 35" Type of Grout's I I Irrigation -Approx. Depth I I Eastern Surface Seal installed by r;ontraar+t–r- - Repair Work Done ❑ Type of Pump H.P. State Work Done t Well Destruction ❑ Well Diameter R_7Srt Sealing Material (top 501 X Monitoring Depth Filler Material lBelow 50') TYPE OF SEPTIC WORK: NEW INSTALLATION la REPAIR/ADDITION f I DESTRUCTION E 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 to LEACHING LINE ❑'! No. & Length of fines Total length/size FILTER BED ❑„ Distance to nearest: Well Foundation Property Line k SEEPAGE PITS l I Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑'t 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 f 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." SAN JOAQUIN LOCAL HEALTH DISTRICT The applicant m t cI far all required inspections. omplete drawing on reverse side. VIRONMENTAL HE [ Signed X Title: GC�o� l �' SPECS. P WR FUR DEPARTMENT USE O LY-�)L)PCn", 1+ 3i Application Accepted by date Is_1S Ar a i - Pit or Grout Inspection by DateSY.L_15� Final Inspection b Date Q3 Additional Comments: ❑ 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 . r INFO AMOUNT DUE AMOUNT REMITTED ASH RECEIVED BY DATE PERMIT'NO. a,EH 13-24(REV.1/H 5) EH - .ao Inas , r- 5