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APPLICATION .FOR PERMIT SAN JOAQUIN.LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED _IJL)r� 141. (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.phis application 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. Job Address .( ,%� �-lL-,. `��ql 1 ,� � City_ A '.f� Lot Size PM F � PhoOwner's Name Address ContractorgessneP ho�I�1ne* n - i TYPE OF WELL/PUMP: NEW WELL jW WELL REPLACEMENT DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS: yy INTENDED USE TYPE OF WELL PROP EM AREA CONSTRUCTION SPECIFICATIONS a 41 ❑�Industrial ❑ Open Bottom anteca Dia. of Well Excavation Dia. of Well Casing i £�Domestic/Private 8'f'ravel Pack ❑ Tracy Type of Casing 0alc IT Specifications 1 ❑ Public ! ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation i DD Approx. Depth ❑ Eastern Surface Seal Installed by t ' Repair Work Done ❑ Type of Pump H.P. State Work Done t Well Destruction ❑ Well Diameter Sealing Material'(top__50') ~yy _ d ` Depth Filler Material (Bellow 501 I f 0 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIRlAQDITION El DESTRUCTION ❑ (No septic system permitted if public lsewer is —.... _ j s available within 200 feet.) Installation will serve: Resit noe'' S.Y.Commercial Other `s k Number of living units: Number.of bedrooms - Character of soil to a depth of 3 feet: t Water table depth 14 SEPTIC TANK ❑ Type/Mfg a Capacity No. Compartments 4 PKG. TREATMENT PLT. ❑ Method of Disposal Y - Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size l7 FILTER BED ❑ Distance to nearest: Well Foundation t Property Line , SEEPAGE PITS ❑ Depth Size s,'Numlb�e_r� SUMPS LJ Distance to nearest: Well' " Foundation w,." Property Line DISPOSAL PONDS ❑ hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, sfate-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 -e performance of-the work for which this permit is issubd, 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 workma 1 s compensa- tion laws of California." + The applican II r all uire ctions. Complete drawing on rev side. Signed XTitle: `" :'� Date: R D PARTNIEN7 USE,ONLY� ¢ , Application Accepted by Date - IQ Area --5 Pit or Grout Inspection by OatA340Z Final Inspection by Date l Additional Comments: fold "i teAV ❑ Stk 48Cr6781 ❑ Lodi. 369-3621 -❑ Manteca -7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201FEE t INFO AMOUNT DUE AMOUNT REMITTED CASH CK 9 RECEIVED BY DATE PERMITNO. + EH 1324{REV.I/a!5) EH 14-28 �to .