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'Y APPLICATION FOR PERMIT r SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone {209} 466-6781 t a 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 applicationf 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 _ y. -I � =DACity AcAh&po Lot Size V.1 QCaes PM • Owner's Name 2 Address Phone F Contractor's Name th Iri Q License No. —3 Phone D 7 2 q i TYPE OF WELL/PUMP: , NEW WELL WELL REPLACEMENT X T y DESTRUCTION;$ i 1 PUMP INSTALLATION SYSTEM-REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK In Q.&e-_ SEWER LINES DISPOSAL FLDAAer PROP. LINE i FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS lBitG INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS o I ❑ Industrial §Upen Bottorn"' ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing1, I 1 Specifications 4 ❑ Public ❑ Other ❑ Delta Depth of Grout Seal .41Type f Grout K D I ❑ Irrigation 9712__q { pproxDepth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. 3 1 State Work Done Well Destruction Well Diameter ` { ---tomSealing Material (top 50'►` f R II Depth 12 TL7 ('Filler Material {Below 50'j Ll 1 R TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is I - available within 200 feet.] Installation will serve: Residence_ ,Commercial .,Other, Number of living units: Number of bedrooms k Character of soil to a depth of 3 feet:1 I I Water table depth SEPTIC TANK ❑ Type/Mfg 4- - I Ca aci tY No. Compartments PKG. TREATMENT PLT. F] P I A trF< Method of Disposal Distance to nearest: Well " ' 1 Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size 'FILTER BED""�"`"'"'❑�Distance'to'nearest: `"Well' '""" "Foundation'°�— .Property SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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 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."Contractor's 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 m st call for all required Inspections. Complete drawing on reverse side. I Signed �G ^�-• .Title:- Date: " � I 3 FOR DEPARTMENT USE ONLY Application Accepted by p Date Area Pit or ro t Inspection by Date �? Final Inspection by Date Additional Comments: ❑ Stk 466-6781 Lodi 369-3521 ❑ Manteca 823-7104 Tracy 835- Applicant- Return all c pies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 _r y I FEE AMOUNT DUE AMOUNT REMITTED t INFO CASH RECEIVED BY DATE PERMIT"NO. EH 13-24�14D 9(l.-2 YS- EH+ 1426IAEV,10/a3) ^_�