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APPLICATION FOR PERMIT r SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is heieby 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 welUpump and the Rules and Regulations of the San Joaquin Local Health District. -31 ` 'e-5q2— —.1:1 -C-2-Z-- 1 eF 2-8 bus.wa Job Address / AWCCity Lot Size PM Owner's Name Contractor !:�_e/ Iy 5 M d d r e s s � � License No.w a.��Phane TYPE OF WELL/PUMP: r. s N WELL WELL`REPLA£EMENT_Q DESTRUCTION ❑ PUMP INSTALLATIONSYSTEM REPAIR ❑- OTHER ❑ 1 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES 1� `x'DISPOSAL FLD. PROP. LINE FOUNDATION - 130 AGRICULTURE WELL OTHER WELL —y PITS/SUMPS )NTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIO �f '04ndustrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation_ Dia.oYWell Casing XDomestic!Private �9 Gravel Pack ❑ Tracy Type of Casing ` Specifications (`l Public //❑ O1her 1 1 Delta Depth of Grout Seal 1� .'Type of Grout.'� �_ i i I Irrigation / pprox. Depth 11/Eastern Surface Sedl Installed by ,!"/�!�GA41< _ Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material Itop 501 f Depth Filler Material (Below 501 E —_ TYPE OF SEPTIC WORK: NEW INSTALLATION I] REPAIRIADDITION l 1 DESTRUCTION l 1 (No septic system permitted if public sewer is available within 200 feet) Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms } Character of soil to a depth of 3 feet: r Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments d a PKG. TREATMENT PLT. © Method of Disposal Distance to nearest: Well Foundation Property Line i LEACHING DINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE,,PITS l I Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line r DISPOSAL PONDS ❑ 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 h rules and regulations of the San Joaquin Local Health District. 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 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 u t al qu' ns. Complete drawing on a arse side. Signed X itle: Date: F F. DEPARTMENT USE ONLY . Applicati cepted b1by Date L4—b4-9,_0__ Area + f Pit or rou spection Date QtZ Final Inspection try Date -6/V_ Additional Comments: i ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Mant ca -7104 U ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601.E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 INF MOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. Cl to +.EH}3-24(REV.1/H 51 t/.,�r� /�A O EH 14-28 �� _ —[