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APPLICATION FOR PERMIT "' 1 SAN JOAO.UIN"LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA.,, Telephone (209) 466-6781 r PERMIT EXPIRES 1'YEAR`FROM DATE•ISSUED (Complete in Triplicate) a 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 I made in compliance with San Joaquin County Ordinance No.549 for sewage or No. i862"for well/pump and the Ryles and Regulations of the San Joaquin .Local Health District. r. rr0;�,dT ' -�I , - -•,. .M to DC, Jab Address �`?la3l DP.i�Lch�. �61�7DS City 7 Lot Size PM Owner's Name _E21 570_-1 lb Address 7 �°/~ Phone Contractor A, r /�- G Address PIC>/ !'� M License No. Phone TYPE OF WELL/PUMP. NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHE_R,-❑ { DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. /' PROP. LINE f FOUNDATION AGRICULTURE WELL OTHER WELL' PITS/SUMPS _ i 1� s ' INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Q Industrial ❑ Open Bottom ' ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ~- ❑ Domestic/Private # ❑ Gravel Pack ❑ Tracy Type of Casing Specifications A ! 9-D' ❑ Public ❑ Other ❑ Delta Depth of Grout Seal __. _ Type.of Grout i ❑ Irrigation Approx. Depth ❑ Eastern Surface Seal Installed by i Repair Work,Done ❑T Type of Pump H.P. State Work Done , 4 Well Destruction ❑ Well.Diameter Sealing Material (top 50') Depth .Filler 1Material`(Below 50') i 4 11f TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ 'DESTRUCTION ❑ (No septic system permitted if public sewer is -tl " available within_200 feet.) Installation will serve:` Residence Commercial's Other Number of Irving units: Number of bedrooms,f��, �' Character of soil-to aidepth of 3 feet: �4 D p 5 I Water-table depth SEPTIC TANK j. ❑ Type/Mfg l Capacity No. Compartments j PKG. TREATMENT PLT. ❑ #� `Method'of Disposal Q. ¢ Distance Ito nearest: Well Foundation Property Line LEACHING LINE No. & Lehgth of lines Z/,6 �" Total length/size < 1 FILTER BED Distance Gto nearest: WeiFoundation Property_Line. SEEPAGE PITS ❑ I� �Tr f ize " /X t F p ' Number Depth S } i SUMPS Distance'Ito nearest: Well Foundation` Property Line_ DISPOSAL PONDS ❑ 1 hereby certify that I have prepared this application and-that-the-work-wilI 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 the following: "I certify that in the performance of theworkfor which this permit is issued,:l 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 permiis-issued,I shall employ persons subject to workman's compensa- tion laws of California."a ; t The applicant must call ifor II red/,inspections. Complete dtawing on revbrse side. f Signed Date; Ih F l+ i OR DEPARTMENT USE ONLY k Application Accepted by •I ��d"c /f/ ' Date Z Area e-7 p Pit or Grout Inspection by " Date Final Inspection by Date �7 Additional Comments: ❑ Stk 466-6781 i❑ 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 { ' FEE y AMOUNT DUE 1 AMOUNT REMITTEDh CK# RECEIVED BY DATE _ PEgM17-NO. �. .:INFQ +t ( - -- - .*CASH. -, + EN 13-24(REV. k +YS_��J �)-t_s- ° r'I/� �Z 3o r ; 15- EH f5[Sl h ' 1 w. EH 1428 � '' •.