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APPLICATION FOR PERMIT _ SAN JOAQUIN LOCAL HEALTH-DISTRICT f 1601 E. HAZEL T ON AVE., STOCKTON, CA ... k G„ Telephone (209) 466-6781 .;PERMIT EXPIRES 9 YEAR FROM DATE ISSUED (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 41 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 i� 3• ,f' F �yy+ Yn � _ /Sts !' c�� 1 .�'2 city fx c �Lt�Y Lot Size 2AO o k 2 dD PM _. , Owner's Name eo jT Address Phone -----• -- 3��,; ,-..... ,.,,,�,.:. """'"rte--.-�,.-.� ,��.,-.�,� .s,.�- �.` ` Contractor's Name - ' ,License No. Z4Phone f TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ � ,>,j PUMP INSTALLATION ElSYSTEM REPAIR ElOTHER ❑ *- ' DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES 1 DISPOSAL FLD. PROP. LINE - FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS Vl� INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation ;Dia. of Well Casing 1 ❑ Domestic/Private ❑ Gravel Pack © Tracy F Type of Casing Specifications /�q' ' Q Public El Other -1 Delta Depth of Grout Seal Type'of Grout "I [ C -�'igation ..`Approx. Depth, E].`Eastern Surface Seal Installed by ��r Repair Work Done El Type of Pump H.P. State Work Done Well"Destruction- ❑ Well Diameter Sealing Material (top 50`) � '` " "`f. •• Depth Filler Material (Beloe') � ' TYPE OF-SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION li,DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other 1 s „ Number of living units: 2- Number of bedrooms Character of soil to a depth of 3 feet: " Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments F I PKG. TREATMENT PLT. ❑ Method of Disposal ` Distance to nearest: Well Foundation_ 7rPropert-Line `. _ y R LEACHING LINE 2--'No. & Length of lines i Total length/size FILTER BED ❑ Distance to nearest: -Well_ Foundation • Property Line 6"0- SEEPAGE PITS Depth - z� Sizes 7SL Number SUMPS;: ❑ Distance to-nearest: --w %4 Property-Lined ' DISPOSAL PONDS_ _- ❑ 'f # e f 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 LocalZHealthDistrict. Home owner or licensed agent's signature,cartifies the following: "I certify that in the performance of the work for which-this permit is issued, I shall not j employ any person in such.manner as to become subject to workman's compensation laws of California." Contractor s hiririgor sub-caniracting 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- i -tion laws of California." ! The ap?licant!.93uV call for all required inspections. Complete*drawing on reverse Signed Title: Data: _7/Z_ -3 l'� i FOR DEPARTMENT USE ONLY t f r Application.Accepted by Date 7"Y �' a Area E : y Pit or Grout Inspection by Date Final Inspection by Date � f Additional Comments: 1 _ Stk 466-6781 ❑ Lodi 369-3621 r ❑ Manteca 82.3-7104 ❑ Tracy 835-63$5 I A❑pplicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE CK INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT"NO. i + EH W26 iREV.101831 L4 r - a '."T"�.- ' �1 f.`cf 7 -