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- APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT R 1601 E. HAZETON AVE., STOCKTON, CA 'Telephone (209) 466-6781 PERMIT EXPIRES 1-YEAR FROM DATE ISSUED /Po0a/77i-f (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 1 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. � srr�t.�T S7reert ��td4 eters S fry Job Address'14Z6V hjr] 11%09- t-tcyiQT- hl C -U too?;-� /J�� fQ�i City ;Lot Size PM -s h. Pry - 9,:0 Rzrx I's S41Owner's Name v �'tn Address I�r� �� Phon<-10Q b 9•- 3ftn Contractor-11"k>< C'.a..�411 Kt 1 5 AddrL.Sri gi1svP1S`r'87ist '�+4r.1'A-fa^ ��icenr ese No. _Ph, -77 TYPE OF WELL/PUMP: NEW WELL ❑ k -WE_LL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER W%�$rOof iw�5 (Z) DISTANCE;TQ-NEAR EST:-SEPTICfT-ANKy- ` ''.SEWER LINES DISPOSAL FLD. PROP. LINE -. / .. "'tis a. . "..� .��-LINES_--.D• _.. _� r ,�11 FOUNDATION' -+ AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL '+,,PROBLEM AREA CONSTRUCTION SPECIFICATIONS F LlIndustrial-,., ❑ 0 en Bottom s ~ �, p ❑ Manteca Dia. of Wel! Excavation 3.0>'.r..c1,?a Dia. of Well Casing ❑ Domestic/Private `s: ❑ Gravel Pack ❑ Trac a of Casing Tracy yp 9 Specifications 'r I Public I_I Oiher R Delta Depth-of Grout Seal Type of Grout I I Irrigation h J �.-Approx.,Depth it 1 Eastern Surtace Seal-Installed by'�� _ ' -Repair Work Done ❑ Type of Pump.. H.P. ,.State Work Done_ Well Destruction ❑ Well Diameter Sealing Material (top 501 r Depth Filler Material (Below 50'1 f' TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION L]}DESTRUCTION l I (No septic system permitted if public sewer is available within 200 feet.) r Installation will serve: Residence_T Commercial— Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: SEPTIC TANK Water"table depth ❑ Type/Mfg Capacity No..Compartments PKG.TREATMENT PLT. ❑ Method of Disposal" Distance to nearest: Well Foundation Property Line + ! LEACHING LINE ❑ No. & Length of lines �-,Total length/size { FILTER BED r ❑ Distance to nearest- Well Foundation L -.Property Line ... . SEEPAGE PITS 11 Depth 5ixe to nearest: =1 lrWeil - -= `"T - _ R riiundation_ +-e+s'�proplerry nem ■� .� �..,! DISPOSAL PONDS C3 thereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, ani #° 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 shalt 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." The applicant must call for al requ' inspections. Complete drawing on reverse side. Signed X •D/1 Title: t F-i 4 r✓ ld.PJ2��' F (t �(% O DEPARTMENT USE ONLY / Application Accepted by Date /`f I a 4p ��P( [Area, Pit or Grout Inspection by Data Final Inspection by Additional Comments: �� i^ tl�v 4} C) Stk 466-6781 CI Lod 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - eturn all copies to`nviron ental Health Permit/Services 1601 E. Hazelton Ave. P.O. Bo S,,*., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED ( CK INFO RECEIVED BY DATE PERMIT.NO. + EH IREV.1/N 51 EH 14-24 Awl f l I