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APPLICATION,.FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE TON AVE., STOCKTON, CA 'Telephone'(209) 466-6781 PERMIT EXPIRES I YEAR FROM DATE ISSUED .., 13!N (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 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."'- Job Address 97P/12 eoeeZ s 'Oeo-City. i.6 .s. .. .„ PM Lot Size Owner's Name L7/ L Address r Phone Contractor ZYAddress �2420 ,f�jf�LGa �� License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION �O RE-AnGi� YSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST:_ SEPTIC TANK SEWER IL NES DISPOSAL FLD. PROP. LINE, FOUNDATION AGRICULTURE WELL _' w "0-:f A WELLY PITS/SUMPS-"_7 ' =`— INTENDED -"_7 ' =`—INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ,'Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation ---Approx. Depth El Eastern Surface Seal installed by Repair Work Done El Type of Pump . H.P. I �Z State Work Done Well Destruction Cl Well Diameter Sealing Material'Itop 50'I � Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ INo septic system permitted if public sewer is - available within 200 feet-1 .10 ..0 Installation will serve: Residence Commercial Other Number-of living units: . Number of bedrooms Character of soil to a depth of 3 feet: - Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ T Method of Disposal Distance to nearest: Well Foundation Property Lime LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ .Distance to nearest;- Well Foundation ..- Property Line / DISP � �• OSAL.PONDS ❑ 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 rules and-r_egulairons of the San Joaquin Local Health District—, Home bwner',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 follo+Iving: "I certify that in the performance of the work for which'tFiis permit is issued,1 shall employ s p y persons subject to workman's compensa- tion laws of California. ZZ " 1 The applicant 'j II f all rered ii�pections. Complete,drawing on eva side. Signed X f / Title: V.5Date: 11-10 FOR DEPARTMEN US ONLY :'- _W ,17 ol Application Accuted by Date ►e ,< - ` "- Pit or Grout Inspection by _� Date incl Inspection b � ate y` - ..' r ' Additibnal Comments: t �3 * y _❑_Stk466-6781_ rED_Lodi-369.3621 ._—❑_Manteca.,..823-7:104-- ----0 Tracy-835-6385 - --- - _ Y „m - ' --- q i Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 952W.-- ;.2FEE . CrN 17% INFO AMOUNT DUE`' CK °y ` AMOUNT`REMITTED CASH A RECEIVED BY DATE �` PERMIT'NO. + EH 13-24{REV.tiie51 EH 14.28 C` 6O. ._ k 9 1 F i�l� t %.L,"t J �