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APPLICATIOWFOR PERMIT 0 SAN JOAQUIN LOCAL HEALTH-DISTRICT ` 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 R PERMIT EXPIRES TYEAR FROM DATE ISSUED - 6 _ (Complete in Triplicate) Application is heteby,made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is ti 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. s Job-Address City 46 42t, Lot Size PM ff r Owner's Name Address .7�q_.2�.r Phone Z3 7 Contractor �4�2��-�AddressLicense No.J�«3 jJ�f Z,/ Phone Z f TYPE OF WELL/PUMP: NEW W WELL REP EMFNT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ ,•;" kr DISTANCE TO NEAREST: SEPTIC TANV,5, SEWER LINES DISPOSAL FLD. PROP. LINE " k -� FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS / w� El Industrial ❑ Open Bottom ❑ Manteca Dia.'of-Weld-Excavation•/Z. Dia. of Well Casing 4a �� f Domestic/Private p ;K Gravel Pack ❑ Tracy Type of Casing G'. Specifications Cl"Public Cl Other F1 Delia depth of Grout Seal100 ype of Grout�� r k 1 1 Irrigation , Approx. Depth I I Eastern Surface �7 Seal'lnsta(led by��_ toZtia.11C3 Repair�Work Done ❑ Type of Pump _ H.P. Z.. /!State Wor _Done"_ Well Destruction ❑ Well Diameter Sealing Material (top 50') ca Depth Filler Material'(Below-50.)_. A c TYPE OF SEPTIC WORK: NEW INSTALLATION i 1 REPAIRIADDITION 1 1 DESTRUCTION 11 '(No.sepfic system permitted if public sewer is ,q available within 200 feet.) Installation will serve: Residence_____ Commercial_ Other Number of living units: Number of bedrooms 'k _. _ Character of soil to a•depth of 3 feet: Water table depth L1/1 SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments r PKG. TREATMENT.PLT. ❑ Method of Disposal Dista ce.to nearest: Well Foundation Property Line ' LEACHING LINE ❑ No.'&„Length of-lin-es— Total length/size r FILTER BED ❑ Distance to nearest: ”Well Foundation Property Line SEEPAGE PITS I I Depth Size _ Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL 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 regulations of the San Joaquin Local Health District. f 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 r 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." I Thea applicant call for all r , pp quired ' cti Complete drawing on reverse side. Signed X Title:t tl .{ Date: DEPARTMENT USE ONLY r� Application Accepted by ` Date 11 Area 1 Pit or rout ns ction b Pe Y Date Final Inspection by atk � Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca -7104' ❑ Tracy 835.6385 a "' I Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazalton Ave., P.O. Box 2009, Stk., CA 95201 FE E INFO OUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT"NO. Sze+.EH 14-24(REV.r/K 51 L ps 0 Q�[ / 1F G D 10 t EH 14-2a C L lam[ !� f C! I�-