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4 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 Rules and Regulations of the San Joaquin Local Health District. Job Address rO Q 2— !{v+�LJ "l/+ City Lot Size PM Owner's Name Address `s Z - Phone Contractors �T A i�ddress, z /'' f-,License No-Yffj n.Phon ITYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ I1 '-PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPtIC.TANK' SEWER LINES DISPOSAL FLD. PROP. LINE FOUNpAT,ION t AGRICULTURE WELL OTHER WELL J PITS/SUMPS INTENDED USE ' TYPE OF WELL -PROBLEM AREA CONSTRUCTION SPECIFICATIONS i ❑ Industrial ❑ Open Bottom `17 Manteca Dia. of Well Excavation Dia. of Well Casing � � i s 71 11❑ Gravel Pack ❑1'`fracyType of Casing Specifications ❑ Public F ❑ Other - ❑ Delta ,,,Depth of.Grout_SeaI-.-.—= - - --...»-Type of Grout I 10 Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by E Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction O Well Diameter Sealing Material (top 50') Depth Filler Material (Below 501 I f :TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITIO ❑ STRUCTIO ❑ (No septic system permitted if public sewer is av table within 200 eet.) 1 Installation will serve: Residence____ Commercial_ Other_r Number of living units: Number of bedrooms 14-0111 CVkl r 4 Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg. Capacity No. Compartments .,.. !PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line l { i t �LEACHING LINE �-�°-0�'^Nor&-tength�af1inesTatai'lengtfi/size-"""``' 1 f :FILTER BED ❑ Distance to nearest: Well Foundation Property.Line 6 I _ SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line r DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will be,done in accordance with $an'Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. i Home owner or licensed agent's signature certifies the following: "I certify that in the performance of thea w&ik`for:which this permit is issued, I shall not employ any person in such manner a`s.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 mut call for all re d inspec'ons. Complete drawing on reverse side. C t Signed Title: I Date: t FOR DEPARTMENT USE ONLY Application Accepted_byi Date Area ` Pit or Grout Inspection by Date Final Inspection by Date Ch3 r' I Additional Comments: Oldq �4 °( ❑ Stk 466-6781 ❑ Lodi 369-3621 F6 Manteca 823-7104 ❑ Tracy 1 Applicant Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 201 Stk., CA 95201FEE _ INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. + EC H 13-24{HEV.IieW V-1 l•63 EH 1426 i