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APPLICATION.FOR PERMIT + r i "• t. W SAN JOAQUIN. LOCAL HEALTH DISTRICT ` •. ` 1601 E. HAZELTON AVE., STOCKTON, CA �•. Telephone (209} 466-6781 PERIVI'IT EXPIRES 1 YEAR FROM DATE ISSUED s `4" (Complete in Triplidate) a +h 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 corripliance'wl'th 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._ /46-D, . �ti '- r R Joh Address / City Lot Size PM Owner's Name °� �. [� C y Phone 9� - =�_ �r1 �� Address r„�Contractor s Name , G� ' GLlcerlse No. 3090 VO L Ict, rk r Phone F TYPE OF WEGI/PUMP., NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ ,kms-L R.., SYSTEM REPAIR ❑ y s;i 4 k l .,PUMP INSTALLATION OTHER ❑ / DISTA4C:E*TO NEAREST k SEPTIC TANK SEWER LINES 3 i'l,t DISPOSAL FLD. PROP. LINE O' FOUNDATION AGRICULTURE WELL ' OTHER WELL PITS/SUMPS SS t'INTENDED USE t `TYPE.OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS- f s, ❑�Industrlal ❑AOpen Bottom - ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ,rnaStle%Pnvate 'avel Pack `. ❑ Tracy Type of Casing . Specifications 1 f ❑ PujiLc� 3 N''. G7't7#her ;` ❑ Delta Depth of Grout Seal f� r°_ ai } a ' P Type f Grout t 1M Li r ❑I�rEgation �•. J 4pproz. Depth Eastern Surface Seal Installed by C. G y �hRebairWvrk D"ono ; ❑; Type of;Pump H.P. kn State Work Done c s WeII:Destructiph ❑ Well.-piameter Sealing Material (top 501 i' f -,'.'Depth Filler Material (Below 501 E TYPE".OF SEPTIC WORK: NEIN INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION Q Mo septic system permitted if public sewer is (p •. _ s available within 200 feet.) 77� Installation will server Residence Commercial_ Other '.i,,Nurimber of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table'depth SEPTIC TANK ❑ Type/Mfg 1 / s, Capacity 'ryNo. Compartments / PKG. TREATMENT PLT. ❑ J'4{" ~ / i Method of Disposal Distance to nearest: Well Foundation" Property Line 4 ��. y F LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line 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: "l 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 applica u call for all required ' pections omplet rawing on rever a� e. Signed Title: `" iQ �, Date: , ` FOR DEPARTMENT USE ONLY � u Application Accepted by Date %�� Area Pit o rou Inspection by Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy $3546385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 ;,AMOUNT AMOUNT REMITTED --R AMOUNT;DUE- �- _ ' "DK' RECEIVED 13Y- 13-24 Y � DATE-, PERMIT`N07 ^CASH--� + EH 13-241REV. EH 10/831 1428 �17/gS �5 -S7o