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APPLICATION FOR PERMIT F SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON 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 and/or install the work herein described. This application is I 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 Distri'c't` OAST ; y, Job Address _� OA r a 0 M S lock Rd City S/mac k4a31 Lot Size. 410 PM i Owner's Namew,%(Lyn Jn DL. C aft,"J, ddress `� j _ Phone C Contractor 1 urVraYWC i6 �'AlAddress P0 goxLicense No.3777dea7 -1' Phone 1 TYPE OF WELL/PUMP: NEW WELL !d WELL REPLACEMENT ❑ DESTRUCTION El PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PETS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 2 ob ❑ Domestic/Private L1 Gravel Pack EI Tracy Type of Casing e� Specificationsot: 316 k f"1 Public f_1 Other 1-1 Delta Depth of Grout Seal 0 Type of Grout _ + Irrigation __Approx. 0 th I 1 Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump j�rbfl�e H.P. State Work Done _ Well Destruction ❑ Well Diameterg -�-�_. Sealing Material Itop 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION I 1 DESTRUCTION I 1 INo septic system permitted if public sewer is available within 200 feet.) Installation willResidence— Commercial_ Other Vi Number of living units: Number of bedrooms 0 Character of soil to a depth o feet: Water table depth SEPTIC TANK ❑ Type/ Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal + Distance to neares . Well Foundation Property Line LEACHING LINE Q No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS { I Depth Size , Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS 0 I 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 E 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." The applicant must call r ired inspections. Complete drawing on reverse side, Signed X Title: % Date: 6- �P0 FOR DEPARTMENT USE ONLY Application Accepted by Date Area }} Pit or Grout Inspection by Date Final Inspection by 'Date Additional Comments: ❑ Stk 466-6781 ❑ adi 369-3621 ❑ Manteca 523 7104 ❑ Tracy 835-6385 Applicant- Return all co ies to: Environmental Health Permit/Services.1601.E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT{(EMITTED CK RECEIVED BY INFO CASH DATE PERMIT'NO. + EH 13-24 IHEV. /n 51 10/ 477 EH 14-26