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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA " Telephone (209) 466-6781 PERMIT EXPIRES 1 YIEAR FROM DATE ISSUED (Complete in Triplicate) c Application is hereby made to the San JoaqujnrCoca�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 i Local Health District. If f Job Address %�'C "eii /''"r' City Lot Size20 a_e��_ PM Owners Name t �ddr.ss, O,&oxo 50 .74 . .CA,_.Phone Cont%act T ,� 1�" Address/ lP/7 � r_.License No.32Phone TYPE OF WELL/PUMP.. _.NEW.WELL_❑r_-___.._.. __ WELLREPLACEMENT ❑ �. ._ DESTRUCTION.0 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE b. FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS.., INTENDEI] USE 4 TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS } ❑ Industrial 'i ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing f" El f)omestic/Private L1 Gravel Pack ❑ Tracy Type of Casing """"""""""Speci(ic�tioils ) � r 4;1 Public ; n Other ❑ Delta Depth of Grout Seal Type,of Grout I ] Irrigation' �• Approx. Depth I ] Eastern Surface Seal Installe�d---by, fiepair Work:'Done^--fU— Type of Pump H.P. % State Work Done . Well Destruction ❑ Well Diameter Sealing Material (top 501 r5 Depth r Material (Below 501 I TYPE-OF"SEPTIC WORK:: NEW INSTALLATION l 1 R PAER/ DDITIONX DLSTHUCTION I 1 (No septic system permitted if public sewer is � available within 200 feet.) f 1 Installation will serve: Residence II/Commercial_Other � f 1 -Number of living units Number of aorrls Character of soil to a depth of.3 feet-. Water table depth SEPTIC TANK ❑ Type' 1, Capacity No. Compartments r KG. TREATMENT PLT. ❑ " ` Method of Disposal i R Distance-to,nearest: Weil Foundation Property Line LEACHING LINE No. & Length of tis. _ -- - Total length/size FILTER BED .t ❑ Distance to nearest: Well eS D Foundation /0 t Property Line i SEEPAGE PITS Depth Size Dumber _ SUMPS Ll Distance to nearest: Well/��'� Fou dation�, Property Line 1� ,..[DISPOSAL PONDS._r r 0 g t I hereby certjfy that i have prepared this application and that the work will be done in_accordance with San Jdaquin county ordiriances,state-laws;an . rules and regulations of the San Joaquin Local Health District. 1 -t.� 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 oPGalifornia."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,1 shall employ persons subject to workman's compensa- tion laws of California." The applicant m st II for all r q 'red ' spections. Complete drawing on reverse si e Signed X Title: abate: ~ r O FOR ,EPARTMENT USE ONLY Application Accepted by Date S:~ �_ Iov Area I &or Grout Inspection by ate nal Inspection b� Data 1 a 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 FEE AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY DATE PERMIT-N0. INFO +-EH 13-24(REV.1/85) [� q EH 14.29 ��`'�NQ �� d `