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t .w r APPLICATION FOR PERMIT ' SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HA ' . ZEA I ON AVE,, STOCKTON, CA l Telephone (209) 466-678, 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 and/or install the work herein described. This application made H compliance with San Joaquin County Ordinance No.549 for sewage or Na. 1862 far well/pump and the Rules and Regulations of the San Joaquin Job Address r , ` y City Lot Size Owner's Name PM Address 42 Phone I Contractor's Mame "`"""^-.,—a-�- . �.�.-. , ._ TYPE OF WELL/PUMP: License No. ---------- 11 - ----• _ i NEW WELL=❑ WELL REPLAGEMENT ❑ Phone - "`— __ _ _ PUMP INSTALLATION ESTRUCTI DISTANCE TO NEAREST; SEPTIC TANK SYSTEM REPAIR ❑ OTHER ❑ { FOUNDATION EWER LINES ` DISPOSAL FLD. i } � AGRICULTURE WELL —1 PROP. LINE INTENDED USE OTHER WELL PITS/SUMPS TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industvial 1� y'f1 Open Bottom ❑ Manteca Dia. of Well Excavation Domestic/Private Q Gravel Pack Dia. of Well Casing ll Public ❑ Other .j Tracy Type of Casing ❑ Delta �--•Specifications LJ Irrigation of Grout Seal Irrigation Type of brout ~` —Approx. Depth ❑ Eastern Surface Seal Installed by Repair:Work Done ❑ Type of Pump Well Destruction H.P. State Work Done F - „Well Diameter Sealing Material {top 50') T k _ _ Depth- . ll Filler Material (Below 501) wo I TYPE OF SEPTIC WORK; NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ {No septic s { ~� P y tem permitted if public sewer is Installation will serve: Residence_ Commercial available within 200 feet.) Number of living units: Other �,. Number of-bedrooms 4r ; 3 Character of soil to a depth.tof_3.feet: I .-- r i SEPTIC TANK Water table depth ❑ ,Type%Mfg 'st "--- _ PKG. TREATMENT PLT. ❑ t _. Capacity—. No. Compartments r Distance to nearest: a Well Method of Disposal t Foundation�f Property Line f1 ; 'LEACHING LINE ❑ No. & Length of lines `S'Z FILTER BED r, r ❑� Distance Oto nearest: Well Tota! length/size Q Foundation_ Property Line SEEPAGE-PITS s E SUMPS f { ;d ,Depth t Size l ❑ Distance to nearest: Number A DISPOSAL PONDS F-1r i Well Foundation Property Line N. I hereby certify that I have prepared this application and that the work will be-done-in accordance with San Joaquin lcourity ordinances, state!a rules and regulations of the San Joaquin Local Health District. Home owner or licensed agent's signature certifies the following, laws, and employ any person in such manner as to become subject to workman's compensation laws of California,"Contractors firing or sub-contracting signature ' "I certify that in the performance of the work for which this permit is issued;I shall not certifies the following: "I certify that in the Performance of the work for which this tion laws of California." permit is issued, I shall em to g I The applicant must call for all required inspections. Complete drawing on reverse side. P y persons subject to workman's compensa- { Signed Title: Inti��- _ _ Date: ' r rtr Date:FOR- ONLY-- � Application Accepted by -. --- -`,` --- `"`•"--�,•—� � � � _ '._ . -•--- - LA `T rea Date Pit or Grout Inspection b , } Yate_. "' fin PMP We by ie_Jt ! Additional Comments: 't} _ r -1 Date ❑ Stk 466-678( ❑ Lodi 369 362 •v - �i�y Applicant- Return all copies to; Environmental He❑althaPermit/Serervices41601 E❑Hazellon Ajve.P P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE INFO AMOUNT REMITTED CK* EH 1324 IAEV-t0f83CASH RECEIVED BY DATE PERMIT"NO. I + 1 R EH 14-26 ! L o Lia ,