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APPLICATION FOR PERMIT I SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 4 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED U (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or instil The work herein described.This app ication 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. f , Job Address,, Curxy Rd.1�Vl .2 MI S. Sargent Rd. Cit>k_-J,0d�. __ Lot Size PM Owner's Nam & PSI Vyds. Address_P,.O. BOX 789 Phone 368-51-34 Contractor's Name , hOUi) 'f•�1ell Drilling License No- � Phone 6$" W I TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR OTHER D DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS k ❑ Industrial ❑ Open Bottom ❑ Manteca ' "Dia. of WeII ExcaVailon Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy t Type of Casing Specifications � ❑ Public 'y � ❑ Other ❑ Delta y` Depth of Grout Seal - Type of Grout [ngation N SA rax. ; '_` pp F�astern rf ce Seal Installed by A,epair Work Done >Type of Pump 'H.P. " Sfate 11Vo k tune _ w Well Destruction ❑ Well Diameter Sealing Material(top 50') J Depth Filler Material',(Belovr 50'1 TYPE OF SEPTIC WORK: NEIN INSTALLATION ❑ REPAIR/ADDITION LlDESTRUCTION ❑ (No septic system permitted if public sewer is ]l . ...t availabl6-Within 200 feet.) Installation will serve: Residence_ Commercial_# Other *' ? 'A Number of living units: LI Number of bedrooms �..,• � ' _ Character of soil to a depth iof 3 feet: ' Water table depth SEPTIC TANK ❑ el Mf ` yp 9 Capacity No. Compartments i PKG. TREATMENT PLT. ❑ 'I� 4: Method of Disposal 1 Distance to nearest: Well Foundation Property Line 9J I 'il ,F LEACHING LINE ❑ No. & Length of lines Total length/size .i FILTER BED ❑ Distance to nearest: Well Foundation Property Line �F. SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Linea" DISPOSAL PONDS ❑ IN I l 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. i Home owner or licensed agent'p 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."Contractors 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 Californi �k The applican us f -equpections. Complete drawing on reverse side. =q Sign Title. Nia.naer Date: �'-3-8� FOR D FITMENT USE ONLY Application Accepted by Date �� Area. -_ ' Pit or Grout Inspection by I� Date Final Inspection by Additional Comments: I� ❑ 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 �yl FEE AMOUNT DUE AMOUNT REMITTED CK# RECEIVED BY DATE PERMIT"NO. INFO CASH - + EH 1324(REV.10183) r - EH 14-26