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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 (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 Rulds and Regulations of the San Joaquin Local Health District. Job Address g�o d fx �r y G/teQ ACL— City Gates Lot Size . /20 0G�!?SM Owner's Name h>` COI11'A,S Address _130 AOX Iao +!OCAe'C-01-el Phone � 4 Contractor_sT,k &ROM,- &2M Address 4L22 Z LJL) e�)O1''' 632,CLicense No,53 0O_ V• Phone 7 Y' -.X TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ . PUMP INSTALLATION U/ SYSTEM REPAIR ❑ OTHER ❑ I DISTANCE TO NEAREST: SEPTIC TANK �w3Q�— SEWER LINES f\' DISPOSAL FLD. PROP. LINE �� s FOUNDATION _I-��F"� AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL - PROBLEM AREA CONSTRUCTION SPECIFICATIONS ; Q� In Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing &Domestic/Private ❑ Gravel Pack ❑ Tracy -Type of Casing k%S%e-d12.4 Specifications F Public Ll Other Cl Delta Depth of Grout Seal Type of Grout.--y Sa,,h I I Irrigation 371—O.Approx. Depth I I Eastern Surface Seal Installed by 1O7n,'L1Cr' Repair Work Done ❑ Type of Pump aS(A13 H.P. 3 State Work Done Well Destruction ❑ Well Diameter Sealing Material Stop 501 J Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION Ia REPAIR/ADDITION I 1 DESTRUCTION I 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: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments., j PKG. TREATMENT PLT. ❑ Method of-Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size- FILTER BED ❑ Distance to nearest: Well Foundation Property"•Line SEEPAGE PITS I ) Depth Size Number SUMPS ❑. Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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, an rules and regulations of the San Joaquin Local Health 132trict. 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 no 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 must call for all required inspections. Complete drawing on�reverse �side. Signed X Title: Date: f - JZcX FOR EPARTMENT USE ONLY Application Accepted by awti Date "l _C6CO Area d� Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ 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 INFO AMOUNT DUE AMOUNT REMITTED K H RECEIVED BY DATE PERMIT•NO. +.EH 13-21(REV.t i K 5) ¢ EH 11-26 i V "� ,f