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r.J 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 (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 Rules and Regulations of the San Joaquin Local Health District. - '` Job Address ` S' City U Lot Size PM ' x Owner's Name S Add ressP, a . � Phone 5��'- T &',-S,. 14 U-35 7`- -irG 3 3 r; 7, s Contractor Addres License No. - Phone— TYPE hone_TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ i PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE DF WEL'—" ' PROBLEM AREA CONSTRUCTION SPECIFICATIONS ! Ll Industrial h CD Bottom.,.. ,,. �❑:Manteca ---� � Dia. of Well Excavation � �, Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack. ❑ Tracy Type of Casing i Specifications EJ Public ❑ Other ❑ Delta Depth of Grout Seal 1 T ❑ Irrigation ° Type of Grout 9 Approx. Depth ❑ Eastern Surface SealAnstalled by ' f Repair Work Dane ❑ Type of Pump 1 H•p,�_ t , t V, State Work Don., Well Destruction ❑ Well Diameter :SbalingFMaterial (top 50'1 1f Depth p Filler,Material {Below 50'1 # TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION (No septic system permitted if public sewer is I ailable within 200 feet.) Installation will serve: Residence Commercial_ Other - ' --Number of living units: Number of bed or oms ".A f - Character of soil to a depth of 3 feet: Water table depth SEPTIC.TANK X Type/Mfg � ' - Capacity No. Compartments PKG. TREATMENT PLT. ElMe#hod of Dispose( Distance to nearest: Weil ____L_"—Foundation =.. Property Line LEACHING LINE ❑- NoT & Length of lines '` ? + _ Total length/siz e FILTER BED - LJ Distance to nearest: Well Foundation Property Line i SEEPAGE PITS LJDe Depth P Size � Number SUMPS C1_ -Distance to nearest: Well I Foundation Property Line . DISPOSAL PONDS ❑ j 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. . 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 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." r' ~_ t The appif y st call for alhrequir ins dons"Complete drawing o reveei;e side. Q� Signed TQC .• Title: r V x Date: p y nR FOR DEPARTMENT USE ONLY ' Application Accepted b V\i11� Date Area Pit or Grout Inspection by Data Final Inspection byrhwr+ r "- ��✓ Dat�7__., i 7� , c✓ 7 X 14' / .: ti,� p d� Additional Comments: J _ ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 623-7104 ❑ Tracy 6385 I Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave.,.P.O• Box,2QQ9, Stk., CA 95201 ' FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE, PERMIT NO. { + EH 13-24 PREY.-+/H57 EH 14-28 4 .00 � �', 1•� l