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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT SPS. —71ZO1` Irve 1601 E. H AZEL T ON AVE., STOCKTON, CA Telephone {209} 466-6781 PERMIT EXPIRES 1-YEAR FROM DATE ISSUED r.. t. (Corhplete 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 Ryles and Regulations of the San Joaquin Local Health District. `' Job Address QUJ City 'M Lot Size` P Owner's Name _ r ^�. Address- hone I 21 P W G. 1. Contractor i,&.i.f tk ddress_ ry TYPE OF WELL/PUMP: License No. {- 54 Phone NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION L2SYSTEM REPAIRX DISTANCE TO NEAREST: SEPTIC TANK OTHER El LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS PITS/SUMPS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation r Domestic/Private ❑ Gravel Pack Dia..of Well Casing ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal 1 ❑ Irrigation r c Type of Grout �Approx.; Depth Eastern Surface Seal Installed by Repair Work Done ,`� Type of Pump • H.P. Well Destruction State Work Done ❑ Well Diameter/�._ � Sealing Material {top 50'1 +� Depth—I� i Filler Material (Below 50') r� TYPE OF SEPTIC WORK; NEW INSTALLATION.'❑ ¢ REPAIR/ADDITION ❑ DESTRUCTION L7 (No septic system permitted if public sewer is \� available within 200 feet.) ! . Installation will serve: Residence,1 Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: I ` SEPTIC TANK ❑ Type/Mf I f, Water table depth b g Capacity.1 No. Compartments `P�TREATMENT PLT. ❑ �. y I ! Method of Disposal Distance to nearest: Well Foundation L Property Line r+ LEACHING LINE =. 0 No--&-LdndOroof"lines'1"-. ^^.�-- •-�- ^--}-^moi; �,- - -� .- ..ze� Total length/si -``"-�.�."r""""'-"_"'"^"--�----- FILTER BED ❑ pistance.to� �Welf,� 1 '~ ' _Foundation. Property_Line. . SEEPAGE PITS L] Depth Size ' � ,Number- :. ....Y = , ,--I Are; SUMPS ❑ Distance to nearest: Well Foundation4; DISPOSAL PONDS ❑ Property'Line' } I hereby certify that I have prepared this application and that the work will be done in`accordance' with Sar�Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. r -Home owner or licensed agent's signature certifies the followin emplo an g "I certify that in the performance of the work for which this permit is issued, !sl ' Y y person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub contracting signature halnot 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 f r ail req 'ed insp'ecti ns. Complete drawing on reverse side. Yt Signed Title: 4120,IL, e{� Date: tl FOR DEPART ENT USE ONLY Application Accepted by Date 4 Area Pit or Grout inspection by Date Final inspection by Date Additional Comments: t ❑ Stk 466-5781 ❑ Lodi 369-3611 ❑ Manteca 823-7104 ❑Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009,gStk., CA 95201 INFO AMOUNT DUE, AMOUNT REMITTED RECEIVED BY f -? =CASH DATE - PERMIT"NO.' + EH 13-24(REV.I/e 51 EH f428