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f APPLICATION FOR PERMIT cm SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA 2 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 $ 1'7 West Essex City StOCktonLot size PM Owner's Name Louise Fisher Address 1.17 West Essex Phone 464-1781. Contractor Cla�kT Well Address 202' ' E Charter Wa.y 'License No. 371560 Phone x'62-7676 I TYPE OF WELL/PUMP: -NEW WELL ❑: � WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION LX _ SYSTEM REPAIR C] OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK,. "SEWER LINES DISPOSAL-FLD. PROP, LiNE FOUNDATION x AGRICULTURE WELL OTHER WELL PITS/SUMPS $ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS �. ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 1 s .Dia. of Well Casing T❑.D.ornestic/P.rivate,,� f�wGravei Pack O_Tracy:�_�� Type of.Casing '�Specifications I f Casing,�,_... F] Public t n Other i� Delta Depth of Grout Seal T. ' ype of Grout I I I irrigation f - �..Approx. Depth I I Eastern ; Surface Seal Installed by x Repair Work Done 0 Type of Pump Sud] H.P. 1HP State Work Done Installed, Well Destruction ❑ Well Diameter Sealing Material (top 501 t De6th Filler Material (Below 501 n TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is" �. � I available within 200 feet.) Installation will serve: Residence— Commercial_ Other r Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: g Water table depth SEPTIC TANK 4 ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation ;• � Property.Line I LEACHING LINE + ❑ No. & Length of lines Total length/size • FILTER BED ❑ Distance to nearest: Well Foundation Property Line y i SEEPAGE PITS I I r Depth + Size Number SUMPS ❑ Distance to nearest: Well Foundation DISPOSAL PONDS Property.Line r t El 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 Diltrict. 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 employ any arson in su manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies 1h f Ilowing: ' c rtify that in tW perfor nce of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws o alifornia. ' F The applic ust cail equ re s�ctip Complete drawing on reverse side. Signed Title: Sec—Tres bate: 1.0/2 /8 8 FOR DEPARTMENT USE ONLY i Application Accepted byIt �Date y� Area Pit or Grout inspection by to Final Inspection by _21- Date�.__ Additional Comments: ..�, ❑ Stk_466-6781 ❑ Lodi 369-3621- ❑ Manteca 823-7104 'r0 Tracy ~835=6385,« Applicant- Return all copies to: Environmental health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 } FEE AMOUNT DUE AMOUNT REMITTED CK INFO CASH RECEIVED BY DATE PERMIT'NO, +.EH 13-24IREV.vK51 EH 14-28