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• a �' a APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 I 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. z00 EAST qi wr MIL RDA City S�Cha Lot Size Job Address 3 PM ,,A c� Owner's Name 7R L (f L Address PI/�lll NO• S Gk7brl/ C4 — Phone Contractors*INM- ROOMlOr1 Address r? Z5 edwr mywn-E 'ST License No._.M-5122.68 Phone(P5)114-Il s TYPE OF WELL/PUMP: NEW WELL LlWELL REPLACEMENT 11DESTRUCTION ❑ r PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER lX S 140A11701q1JG ex DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE 5 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS -2t-!�� ❑ Industrial ❑ Open Bottom E] Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private tKGravel PacltS&D) ❑ Tracy Type of Casing F Specifications ( F1 Public ClOther F1Delta Depth of Grout Sea! T Type of Grout l I Irrigation b.-Approx. Depth I I Eastern Surface Seal installed by CD&�211'�r lw�T� ,0 - - Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 50'! -- TYPE OF SEPTIC WORK: NEW INSTALLATION I:1 REPAIR/ADDITION l 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 t� SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments f ` Disposal of Disp PKG. TREATMENT PLT. ❑ Mei Distance to nearest: Well Foundation Property Line I LEACHING LINE ❑ No. 8 Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I 1 Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 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 Di$trict. 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 f 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 Qinspections. Complete drawing on reverse side. Signed XA M A- Q- d'^'L Title: Date: Z 9 Q f F. R DEPARTMENT USE ONLY I Application Accepted by Date Area / l Pito Gro spection by Date "hinal Inspectio Dat Additridnal 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 CASH RECEIVED BY DATE PERMIT NO. , +.EH 13-24 IREV.1/h 51 D 01 EH 14-26