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i APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED;i t: y _ (Complete in Triplicate)' j 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 N_o.549 for sewage or No. 1862 for well/pump and the Ryles and Regulations of the San Joaquin Local Health District. rf Job Address ` �c NA City Zra e- Lot PM ry Owner's Name t-1w. Lac Address' _ Phone Contractor �I Address _!jt c License NPhone14-OF TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑,f PUMP INSTALLATION E SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK y` `- 'SEWER1LINES`" '� DISPOSAL/'FLD. PROP. LINE i FOUNDATION AGRICULTURE WELL OTHER WELL—' PITS/SUMPS r� r'- ii INTENDED USE _.-7YPEbF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS O Industrial" ❑ Open Bottom ❑ Manteca Dia. of Well Excavation-- Dia. of Well Cating E Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing lF.; Specifications ; ❑Public LlOther i LlDelta Depth of Grout Seale .Type of Grout 6z 4 r ❑ I?rigation ---Approx. Depth ❑ Eastern Surface Seal Installed by ? t Repair Work Done ❑ Type of Pump H.P. gState Work Done µ tf t n� c Well Destruction ❑ Well Diameter Sealing Material atop 50,11w i I uJ Depth? M Filler Material IBelow 501 6 TYPE OF SEPTIG;WORK:` NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCT-ION ❑ (No septic,system'permitted if public sewer Is � ,•k.available within 200 feet.) i r tvlfz� �. Installation wiil.serve: Residence ommercialr ther Number�of living units. � F Number of bedrooms Character,of soil to a depth of 3'feet? ,'A f4- t Water tableldepth r SEPTIC TANK Type/Mfg Capacity ".' " No. Compartments PKG. TREATMENT PLT. ❑ I / ,, ;-Method of Disposal 'I Distance to nearest: Well Foundation' Property Line LEACHING LINE. "No. & L hg th of lines-� - .l✓— ®U�- = f Total length/size AV i FILTER BED � � � Distancepto nearest: Well Foundation 3�p� Property Line I } SEEPAGE PITS ❑ °Depth II: Size 1" 'N —N4 I - Number f SUMPS ❑ Distance'to nearest_: Well Foundation s Property Line DISPOSAL PONDS'l ❑ hereby certify that I have prepared this application and that the,work will.be done in accordance with San Joaquin county ordinancfs, state laws,and rules and regulations of the San Joaquin Local Heaith District. Home owner or licensed agent's signature certif!As 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-�`ppntracting 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" Ikman's compensa- tion laws of California." The applicant must call foe,all quire d ' spectio S. Complete drawing on reverse side. A Signed XTitle: .___.f�� Date:' r, ` t.per t` I FOR DEPARTMENT USE ONLY Application Accepted by �'' w -' ClDat' { �/ Are ' Pit or Grout Inspection by Date. Final Inspection by Date-J I P r Additional Comments: � i ❑ Stk 466-6781 ❑ Lodi 369421 ❑Manteca 823-7104 ❑ Tracy 835-6385 i Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201, CK FEE 1 INFO AMOUNT DUES _ AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. r +EH 13-24�1R EH14-26 EV.t/1351 - w i ' -11A '�l�