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'- APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 ;i PERMIT EXPIRES 1 YEAR FROM DATE ISSUED y (Complete in Triplicate) I 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. �Ro .�� r�3c�, Job Address 2 0 o G� '�%Q/i� � _�_ -_ City A. O�'` Lot Size PM ! Owner's Name (5r4We""SAddress J-300 E' 104 AT ?' ��° ! Phone i . Contractor / �/"iT/SO/1r 'r '� Address �rd� `��' 067 /¢ ' License No. yYy� Phone r TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION t PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ l DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGA ICU,LTURE WELL OTHER WELL PITSISUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I ❑ Industrial, ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications FI Public ❑ Other ❑ Delta Depth.of Grout Seal Type of Grout I I Irrigation —.-Approx. Depth I I Eastern Surface Saul Installed by _ Repair Work Done ❑Y Type of Pump H.P. 'X -' . State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') �} Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDiTION I I DESTRUCTION [ I (No septic system permitted if public sewer is d available within 200 feet.) Installation will serve: Residence_____ Commercial Other Number of living units: Number of bedrooms " I Character of soil to a depth of 3 feet: A+%Or zaRv Water table depth SEPTIC TANK If Type/Mfg C,ssT PV 4Capacity L19n0 No. Compartments ;I PKG. TREATMENT PLT. ❑ - - . - Method of Disposal ;I 1 Distance to nearest: Well f0 Foundation O z Property Line fDO� � � I LEACHING LINE Lf No. & Length of lines 310 Total length/size t S O� t FILTER BED ❑ Distance to nearest: Well /00' Foundation yam'-' Property Line Ldp i t SEEPAGE PITS i I Depth Size / Number ; fSUMPS D Distance to nearest: Well Foundation/ Property Line ff DISPOSAL PONDS ❑ ;I 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 tlrar n the-pe_rformance of the work for which this permit is issued, ! 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: 1 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 mu call for all required inspections. Complete drawing on rev�er Signed X Title:.- Date: k NT USE ONLY I Application Accepted by Date Li A Area I � Q Pit or Grout Inspection by Date Final Inspection by�J ' � Data Lf Additional Comments: ' 6 ❑ Stk 466-6781 ❑ Lodi 369-3 1 ❑ 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 95201FEE �I ( INFO AMOUNT DUE AMOUNT REMITTED CC SH RECEIVED BY DATE PERMIT NO. . EH 13.24[Flev.i/A 5f �� / (, �J ^7 EH.1 4-2tl ` t k