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i , APPLICATION FOR.PERMIT SAN JOAQUIN'LOCAL HEALTH DISTRICT x , k 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES'1 YEAR FROM DATE ISSUES (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.549 for sewage or No. 1862 for well/pump and the Ryles and Regulations of the San Joaquin Local Health District. " .}},,,,,.i ALot Siie Job Address � .IK f� Owner's Name ^'r-�-' UAV�+S Address IOT��50- • ��oi� �VQ� � - Phon 7 Contracto Rddressc:M;2 7r1)>�� License Ivo 7 � Phone 37 TYPE OF WELL/PUMP: NEW WELT- y., . WELL REPLACEMENT DESTRUCTION ❑ PUMP INSTALLATION ❑ iSYSTEM REPAIR ❑ lO�TH'E=�R ❑ DISTANCE TO NEAREST: SEPTIC TANKNO�VE 1 SEWER LINE=S'' 4/0 df Il lk DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL 5 OTHER WELL-- PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICA 10 IS / •' ❑ Industrial Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Wel! Casing (� ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casingi6Vj;� � Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout '~ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done. ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter. Sealing Material ftop 50') Depth Filler Material (Below 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is'� available within 200 feet.) Installation will serve: Residence` Commerciale Other Number of living units: Number of bedrooms Water table depth Character of soil to a depth of 3 feet: r Capacity No. Compartments SEPTIC TANK ❑ Type/Mfg PKG. TREATMENT PLT. ❑ f Method of Disposal j 1 f' Distance to nearest: Well Foundation Property Line i LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED •❑ Distance to nearest: Well Foundation - Property Line SEEPAGE PITS 171 Depth Size Number SUMPS ❑ Distance to nearest: iWell Foundation .Property Line DISPOSAL PONDS ❑ " T 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. h 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 mann r as to become subject to workman's compensation laws of California." Contractors hiring or sub-contracting signature 1X certifies the following: 'I certi t t in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa tion la California.." The plican. cal for q�red ins tions. Complete drawiAnvse 'd Signe TitlDate: f a` =r DR DET USE ONLY Date Area Application Accepted by �-=- I Pit or Grout I ction by a e O��J9JS Final Inspection by ate Ag�a Additional Comments: ° ❑ Stk 466-6781 ❑ Lodi. 369-3621. ❑ Manteca k 823-7104 ❑'.Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 96201 FEE AMOVNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO.' INFO 4 +fH 13-24 IREV.1/13!5 1 ^- EH 1426