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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON•AVE., STOCKTON, CA f Telephone (20) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ^^ ' (Complete in Triplicate) f s •"' ' Application is hereby made to the San Joaquin?Local Heaith District for a permit to construct and/or install the work herein described.This application is J 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. q Job Address 417 J 0 CiI Tod 1<_Tq t Size PM Owner's Name v1,6 Address $_ �i � Phone ds s , f .� p 1� Cf O x; License Na ,� Phone 3/� 34 TYPE OF WELL/PUMP: NEW WELL EJWELL REPLACEMENT❑ DESTRUCTION ❑ PUMP INSTALLATION i SYSTEM REPAIR ❑ ----__.._. p`--- - ---_r --�-_OTHER ❑ DISTANCE T NEAREST: SEPTIC TANK SEWER LINES LIN11 DISPOSAL FLD. �� PROP. LINE i # FOUNDATION I AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Cl Industrial ` ❑ Open Bottom ❑ Mant ca Dia. of Well Excavation ,' Dia. of Well Casing Domestic/Private ❑ Gravel Pack ❑ Tracy` Type of Casing Specifications ❑ Public t ❑ Other- ❑ Delta Depth of Grout Seal Type of Grout - S Irrigation P _Approx, Dept ❑ Eastern Sud a Seal Installed by I Repair Work Done ❑ Type of Pump C1,6 H. ' State Work Done � E X/ST/ 6i Well Destruction ❑ Well Diameter Sealing-Mate rial_top.50.1_ i DepthFiller Material (Below 50') f 1 TYPE OF SEPTIC WORK; NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic.system permitted if public sewer is _J 'Installation tCywill serve: Residence Commercial i � ` available within 200feet.M f Other F s Number of.living units: . Number of bedrooms r Character of soil to a depth of 3 feet: s t I SEPTIC TANK -Water,table depth 1 ❑ Type/Mfg N Capacity No. Compartments I PKG. TREATMENT'PLT. ❑ Method of Disposal I d Distance-to ibrrrest:,�_ Well Property Line f Foundation j LEACHING LINE ❑ No. & Length of lines " FILTER BEDS Total length/sze'N- ❑ Distance to nearest: ' Well Wet Foundation d Property Line i SEEPAGE PITS ❑ Depth Size SU I SUMPSf a� Number C ❑ Distance to neo est: Weil Foundation DISPOSAL PONDS ❑ J N Property Line 3 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. �O 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 l employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or subcontracting signature certifies the following:"I certify that in the Performance of the work for which thisermit is issued,I shall em to tion laws of California." ! 3: p p y persons subject to workman's compensa- The applicant; I VIP all r I inspections. Complete draw i t drawingorv se side Signed LN /1 ��QIT^� � Date: em~ i —F' WDEPART ENT USE ONLY--(�"""" Application Accepted by r Datea Z I Area Pit or Grout Inspection by t Date iFinal Inspection b r Date Q 0 Additional Comments: ❑ Stk�,,466-6781- .❑ Lddir..369 3621 C Manteca 1823-71041 t, ti El Tracy 635 6385 Applicant' Reiu'rn-,all copies to:-Environmen I Health Permit/Service's 1601'E.=Haielton~Ave.�,P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK# ' INFO CASH RECEIVED BY DATE PERMIT'NO. EN 13-24 + EH 14-261REV,7/a5) S ' C y