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t: APPLICATION FOR PERMIT # SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 ' PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct andtor install the work herein described. This application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1662 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. c�+ Job Address oils. C�Moy e a �� City `�` 10A) Lot Size PM �. M � Owner's Name i C Ill Address � �� Phone f .r i $_ g23_K59S/ Contractor !lam � �L Address f`5� V�"�a°`�""`" ^L�icense-No. 41 �Phone�- TYPE OF WELL/EUMP:_. __NEW W-ELL 0 -WELL REPLACEMENT ❑ DESTRUCTION ❑ t ! PUMP INSTALLATION ❑ SYSTEM REPAIR':D_J; OTHER ❑ r , DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES 1 DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE VVEL_L OTHERRRWWELL PITS/SUMPS ; INTENDED USE TYPE OF WELL PROBLEM AREA''N,CONSTRUC710N SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia of_Well Excavation + Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications l"1 Public 17-1 Other Cl Delta Depth of Grout Seal y P Type of Grout I I Irrigation _.-Approx. Depth l I Eastern Surface Seal Installed by - Repair Work Done {l Type of Pump H.P. State Work Done I Well Destruction ❑ Well Diameter Sealing Material (top �0') Depth Filler Material (Below 501 I TYPE OF SEPTIC WORK: NEW INSTALLATION I:] REPAIR/ADDITI ESTRUCTION {No septic system permitted if p lic se er is i "' ` vailable within 200 feet.) a ` 3 Installation will serve: Residence— Commercial ' Other ' w Number of living units: _ Number of bedrooms< Character of soil to a depth of 3 feet: 6 Water tattle depth a SEPTIC TANK ❑'. Type/Mfg Capacity - No. Compartments PKG. TREATMENT PLT. ❑i .,.F #' Method of Disposal j Distance to nearest:/4 Well Foundation Property Line Hook un Ta ztTr Sew"-,t_ r LEACHING LINE ❑y, No & Length of lines r Total length/size FILTER BED ❑ Distance to nearest: Well f Foundation Property Line ^� SEEPAGE PITS ['I Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS^^'-'CY-�^'- �. I hereby certify that I have prepared this application and that tlia work will be done in accordance with San Joaquin county ordinances, state laws, an rules and regulations of the San Joaquin Local Health District: i i 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 k 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 applicant must call for all required spections. Complete drawing on reverse side. Signed X Title, [ cJ Jfic _ Date: ". t FOR DEPARTMENT USE ONLY Application Accepted by �' t - Date �~ Area / Pit or Grout Inspection by ' 1 Date t aFinal inspection by Date CL q A Additional Comments: O 4 ! p I ❑ Stk 466-6781 ❑ Lodi 369-3621./ ❑ Manteca 823-7104 ❑ T acy 835-6&5' 35- 5'-� DLtIn,Q�- t5r i' Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazeiton Ave., P.O. Bo 2009, Stk., CA 95201 i 1 FEEAMOUNT DUE AMOUNT REMITTED CK H RECEIVED BY DATE PERMIT'NO. ��` INFO . EH13-24(A EV.5/As) w �. -'' '°i• jl .� �`�1�� S/iiJ/ EH 1426 ✓✓✓ ! _L