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y 1 APPLICATION FOR PERMIT SAN JOAQUIN' CALi LO* HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466_6781 _ PERMIT EXPIRES 1;YEAR FROM DATE ISSUED'P 5" rs -1,' (Complete In Triplicate} �, } , ..: �7�=- �l D�iZ Application is hereby made to the San Joaquin Local Health District for Wpermit 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 R41es and Regulations of the San Joaquin Local Health District: " n i � y , Job Address ` �`� , l .f 1)+; } Size PM ' Owner's NameC✓/ Address' - - - Phoria r Contrac#orGG� Address �Q mid il, t "��Z 7 /�Z"��3 License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT'❑ DESTRUCTION ❑ r PUMP INSTALLATION 1-1SYSTEM.REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES t � DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ! ❑ Industrial ❑ Open Bottom El Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑'Tracy Type of Casing Specifications , ❑''1 ublic ❑ Other f ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation ----Approx. Deth E3Eastern Surface Seal Installed by Repair Work Done Type of Pump- TH,P• 7_57 _ State Work Done rt Well Destruction ❑ Well Diameter Sealing Material Itop 50') �1r` Depth Filler Material (Below 5(y) TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 20.0 feet.) Installation will serve: Residence_ Commercial— Other F Number of living units; Number of bedrooms S 1 Character of soil to a depth of 3 feet: Water table'depth SEPTIC TANK ❑ Type/Mfg T. Capacity--------- No..Compartments ' PKG. TREATMENT PLT. ❑ J Method of Disposal Distance to nearest: Well Foundatiori Property Line p - I LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance toynearest:, Well Foundation Property Line SEEPAGE PITS ❑ Depth 4Size " Number ! SUMPS ❑ Distance to:nearest: Well Foundation Property Line ! DISPOSAL PONDS ❑ - f hereby certify that I have prepared this application'arld 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 ownericense nt's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ an person in such m ner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies t following:.''I cert' that in the perform a of the o for which this permit is issued, I shall employ persons subject to workman's compensa- tion la of California ' , The ap 'cant m Qr quire m ete dra ing on r side. .Signed DF Title: 01 . Date: 3 f .... FOR DEPARTMENT USE ONLY v1 Application Accepted by Date Area Pit or Grout Inspection by Date Final Inspection by Date jJ< Additional Comments: Stk 466 6781 ❑ Lodi 369-3621 z ❑ Manteca 823-7104 ❑ Tracy 835-6385 -' Applicant Return all copies to: Environmental Health Permit/Servioes 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 , t, t, FEE' i INFO AMOUNT DUE>4, AMOUNT REMITTED G SH RECEIVED BY DATE :::PERMIT.NO, xs 4 + EH13241REV. A"i � If � EH 1426 - 11w 1 C�r... s- [t � 's l "