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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTI ON 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: d Job Address o r e City Lot Size PM Owner's Name rzva4r Address r r Phone t �� l) 7�c 7 a d�G� P0 & Phone 8 O'S� Contract � Address � License No. , TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ s PUMP�I. INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ '- DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL'FLD. PROP. LINE i FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA , CONSTRUCTION SPECIFICATIONS ' ❑ Industrial ❑ Open Bottom ❑ Manteca w—u i.Dia:of,Well:Excavation Dia. of Well Casing r ❑ Domestic/Private' ❑-Gr vei Pack' ❑ Tracy Type-of Casing- Specifications ❑ PublicC3Other 11Delta Depth of Grout Seal Type of Grout ElIrrigation 'IApprox. Depth ❑ Eastern ' Surface Seal Installed by Repair Work Done ❑ Type l!of Pump H.P. State Work Done i Well Destruction: "El � Well Diameter Sealing Material (top 50') - DeptA iller Material (Below 501 TYPE OF SEPTIC WORK: NEIN INSTALLATION ❑ PAI ADDITION 12T DESTRUCTION CI (No septic system permitted if public sewer is available within 200 feet.) Installation will serve_—Residence'n Commercial Other ill Number.f,b r oms / Number of living unifs:� _ _ �?�' - '• ti .-e~ Water table depth Character of,soil to a depth of,3 few-t f -- p SEPTIC TANK '-- --—❑ - Tgpe'/Mfg, Capacity "• No. Compartments y PKG. TREATMENT PL'Tf.•❑ �!I I ''"fir e Method of Disposal I Distance to nearest: �.�/Veil Foundation .° Property Line qo LEACHING LINE e No. &Length of lines Total length/size FILTER BED_` ❑ Distance to nearest: Well 121 aFoundation�0 Property Line SEEPAGE PITS Depth � Size 1. ` - Number .i. SUMPS ❑ Distance to nearest: Well 1,04) Foundation"'eW Property Line DISPOSAL'.PONDS LlIG 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 that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California."Contractors 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 ust call for I lequired inspections. Complete drawing on reverse si Signed iI Title: V, Date: FOR DEPARTMENT USE ONLY ' A Application Accepted by Area Pit �klti�� Pit or Grout Inspection by7f� Date Final Inspection by AA Dater Additional Comments: ❑ Stk 466-6781 ❑ Lodi' 369-3621 ❑ Manteca 823.7104 ❑ Tracy 8356385 Applicant- Return all copies to Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEET DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIVNO. INFO : CASH r + EH 13.2il f�I 4(REV. `7r' C-e-N , O, �f EH 14-28