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Y 7/ �• i i APPLICATION_FOR PERMIT 0SAN JOAQUIN`LOCAL HEALTH DISTRICT ' 1601 E. HAZE T ON AVE., STOCKTON, CA -Telephone 42091 466-6781' PERMIT EXPIRES 1 YEAR'FROM -DATE ISSUED ' G (Comp4lete,in' Triplicate),, : . t 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 Roles and Regulations of the San Joaquin Local Health District. ,. E Job Address City ` / Lot Size /�� 1 PM � �� Owner's Name 1&0 L Address.- f� = p}��n � 3 Contractor LES LT L Address Y' S�_i 1:Y C •D License No,3 �Phone TYPE OF WELL/PUMP:---•- ---a-----NEW-WELL."/]-""'�-'-'-`7 WELL"REPLACEMENT ❑'_ "`" '-DES RUC IT ON❑' 4 PUMP INSTALLATION ❑ I SYSTEM REPAIR ❑ OTHER ❑ .r DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE ' FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation ^ Dia,of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy TYI?, of Casin S Trae r i �..� _ 9 "` ._. pecifications I ❑ Public ❑ Other k11 t ❑ Delta Depth of Grout Seal"" x Type of Grout ❑ Irrigation --Approx. Depth ❑ Eastern s Surface Seal Installed by € Repair Work Done ❑ Type of PumpH.P.` 9 State4Work Done Well Destruction ❑ Well DiameterSealing-Material-(top-50-)_-r Depth F Filler Material (Below 50') / TYPE OF SEPTIC WORK; NEW INSTAL TION ❑ REPAIR/AUDITION ESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: ResidencetfCommercial_ Other ; Number of living units: -—.1 Number of bedrooms 1 Character of soil to a depth of 3 feet: Q {{{ Water table depth k _. SEPTIC TANK ❑. Type/Mfg Capacity i I - No. Compartments PKG. TREATMENT PLT. ❑ 1C r Method of Disposal vv Distance to nearest: ell _ Foundation_ i Property Line - t LEACHING LINE ❑ 'No,f& Length of lines Total length/size f FILTER BED ❑ . Distance to nearest: Well _4 s Foundation Property Line A SEEPAGE PITS ❑ Depth Number F SUMPS Mance to nearest: �IW�e11"� Q E� oundation_� Property Line 3 i DISPOSAL PONDS ❑ _ 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 empl any person in such manner'as to become'subject to workman's compensation laws of California."Contractor's hiring or.sub-contracting signature ' certifies a#ollowing:"I ce 'y that in the performance of the work for which this permit is issued, I shall employ,persons subject''to workman's compensa- tion laws o alifmnia." Thea lice t m t c for all '' w P qui d in ons. x I e drawing on rerse side. SignedDate: FOR DEPARTMENT USE ONLY l ; Application Accepted by Date � Area r Grdut Inspection by t Date�D Final Inspection by DateI t Additional Comments. Stk 466-6781 ❑ Lodi 3621 ❑ Manteca 823-7104 ❑ Tracy 835-63.85 4 Applicant- Return all copies to: E vironmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk.,'CA 95201 vM INFO FEE AMOUNT�UE AMOUNT REMITTED C R RECEIVED BY DATE PERMIT`N0, + EH 13-24(REV.1/8 1 EH 14-26 i