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APPLICATION FOR PERMIT I SAN JOAQUIN LOCALHEALTH DISTRICT 1601 E. HAZEL i ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROWDATE ISSUED 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. 54.9 for sewage or No. 1862 for well/pump_and the Rules and Regulations of the San Joaquin Local Health District. -a7B 7 N . `c _ � Job Address � City � � Lot Size � PM Owner's Name a&)1L rT`--6 Lz- 1 Address`1-;3, 7©7 IAJ!,' C Illeb Phone Contractor 1&&J4r a ZA,tC.ra4_Address 9112 1 "l icense No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENTS DESTRUCTION Z ' PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. .. PROP. LINE FOUNDATION' FAGRICLILTURE WELL""""`� OTHER WELL" INTENDED USE 'TYPE OF WELLmiprPROBLEM AREA CONSTRUCTION SPECIFICATIONS "' ""'` { r: ! ❑ Industrial Open Bottom LJ Manteca Dia. of Well Excavation " Dia. of Well Casing Apomestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing L -.Specifications ❑ Public ❑ Other 1-1DeltaDepth of Grout Seal 4-5-X-201—F Type of Grout t LlIrrigai$oin ---Approx. Depth ❑ Eastern Surface Seal Installed by ' Repair Work Done##h ❑ Type of Pump H.P2 State Work Done # Well Destruction ❑ Well Diameter Sealing Matierial (top 50'1 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ Mo septic syst6m permitted if public sewer is available within'200 feet.),' "" { ~ Installation will serve:- `Residence�— _-Commercial_ Other I r Number of living units: Number of bedrooms r Character of soil to a depth of 3 feet: _ Water,0ble depth I SEPTIC TANK .❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal ' Distance to nearest: Well Fou ndat on Property Line LEACHING LINE /' ❑ No. & Length of lines Total length/`size FILTER BED # ❑ Distance to nearest: JWell y= Foundation Property Line I SEEPAGE PITS ❑ Depth Size ' Number SUMPS ❑ Distance to nearest: Well Foundation Property Line i FDISPOSAL 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. Home owner or licensed agent's signature certifies the4olloWing: "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 sutilect 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 Calif Ia.- The applicant m t all far all re tied inspe i ns. Complete drawing on rerse t(. Ed r/ 3 Signed L-A- Title: t t ms' Date: 4� 147 a F R DEPARTMENT USE-ONLY t ` 3 t+.,rwn�.-� + -'+r--." -w.., -t.. -,- ,r„r,.,w.r...,r —•rf�r.. �.t?:.. �j gz. _..,r,.v_a-..:....N Application Accepted by Dale Pit orro nspection by e - inal Inspection by w t Date Additional Comments: ❑ Stk 466.6761 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy. 835-6385 _ Applicant_ Return ail copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009.Sik., CA 95201 i - FEE it AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'No. INFO CASH l +EH 13-24(REV.I/e 5) - "70•V4 l' to-94' F(f1a17 ` EH 1445 I -