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APPLICATION FOR-PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. H_ AZE;_T ON AVE., STOCKTON, CA Telephone (209) 466•-6781 P 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 Lot Size Owner's Name II f / dress LJNC.ULN QLf� Phone c� .. Contractor's Name ATR 1),�wuf-,'_-W nse No. 4.3'VX_.—._ Phone two - TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ ai DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO./ O PROP. LINE 1CL i` t FOUNDATION AGRICULTURE WELL OTHER WELLITS/SUMPS INTENDED USE Tjl'PE.OF WELL PROBLEM AREA CONSTRUCTION SPECIFICAT!RNS��' ti �.. .. ❑�Industrial � -�----�--�--❑ 0en-Bottam-�,..-w-.❑.Manteca—-..::.,.Dia...of Well Excavation.` /.2 -- Dia.-of Well.Casing-- C5'Damestic/Private a Gravel Pack racy Type of Casing Ar pvc 160_ Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout /O ❑ Irrigation A (-1-Approx.-Depth ❑ Eastern Surface Seal Installed by Repair Work Done IDTyp`of Pump ___...._ H.P. State Work Done ' Well Destruction ❑ Well Diameter l Sealing Material {top 501 AzyZM (y1 F Depth 7-0 Filler Materiai-I-Below-50'M ,92t/.=,...--. TYPE OF,SEP,TIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION ❑ (No septic system permitted if public sewer is �y available within 200 feet.) r Installation w_ill serve: Residence r_ Commercial_ Other Ir F Number of living,units: I!� Number of bedrooms t Character of soil :to a dep"tFiI�Of 3 feet: x.. _ Water table depth SEPTIC TANK ❑ ['Distenlcefto ypg ; �'•Cap'acity t No. Compartments �} PKG. TREATMENT PLT.'❑ � j Method of Disposal ~ I ' nearest: Well; Foundation_ Property Line i LEACHING LINE }❑ 16. & Length of lines ' € Total iength/size_ ;FILTER BED y �❑ Distance to nearest: Well Foundation _ Property Line SEEPAGE PITS et 1,❑ Depth Size Number SUMPS #= I ED `D` istance to nearest: Well'"""""""'^"--Foundation--�= Property Line DISPOSAL PONDS ❑ I. t" 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. 'Home owner or licensed age4s 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."Contractor's hiring or sub contracting signature- icerrifies the following: "I card 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." ` \ I u" 4 . ;The applicant must all or all uired inspections. Complete drawing on rev a side. - SignedI" Title: Date: F DEPARTMENT USE NLY i. �. f3 a i Application Accepted.by. i` } Ci Date ' Area Pit or Grout Inspection by Date $ Final I spection by Date isa .Additional Comments: �L'�� if �� f f _ ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Mante 823-7104 "O Traty 835.6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 1 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT"NO. t: INFO m CASH :r EH 1324 IREV.10183) 3NI tti 3 S EH W28