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j 7 rl APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR 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 1 r 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. R Job Address l ct, City 0C4'* Lot Size 5' AS PM Owner's Name (5QNLO �fJT�K Address X 67 Z AN 91A, Phone Contractor !* d� 50& Address �� L" RJ�Y vim► License No. Yyr'19V Phone s�3 Y� '' TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ r PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ 1 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE $ i FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS r 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 Type of Casing Specifications 9 I"1 Public '.`€ 171 Other 17 Delta,,, depth of Grout Seal Type of Grout--- I rout _I Irrigation —..Approx. Depth I 1 Eastern Surface Seal Installed by r Repair'Work Done" ❑ Type of Pump H.P. State Work Done_ I Well Destruction `❑ Well Diameter Sealing Material (top 501 t Depth i Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION_ .._REP_AIRIADDITION l I DESTRUCTION l I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial— Other 1 Number of living units: % Number of bedrooms IV Character of soil to a depth of 3'feet: S d Water table depth SEPTIC TANK �?I Type/Mfg AT C Capacity �Earo No.-Compartments �. i PKG. TREATMENT PLT. ❑ Method of Disposal t. i 1 Distance to nearest: ;Well Foundation �� Property Line DtJ 4 LEACHING LINE V No. & Length.of dines 3 '�e7 �x -' Total length/size I f FILTER BED ❑ Distance to nearest:; A Well Foundation Property Line IOD SEEPAGE PITS I I Depth. Size Number E' SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ s ry 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 r employ any person in such manner as to become subject to-workman's compensation laws of California."Contractors 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- r tion laws of California." Y The applicant mu t call for all required inspections.;Complete drawing onreverseside. Net t >til ii Signed X Title: ,Date:, # FOR WkARTMENT USE ONLY Q Application Accepted by !ICA-&.n1Date +� 3 # Pit or Grout Inspection by -~~w Date-r f Final Inspection by Date yk Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 C3 Manteca 823-7104' ❑ Tracy 835-6385 i 14 Applicant- Return all copies to: Environmental Health Petmit/Services 1601 E. Hazelton Ave., P.O. Box 2409, Stk., CA 95201 i i FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVEDBY DATE PERMIT'NO. INFO CASH i +.EHt3-24iREV.i/xE) a1 .t� .. y2911 EH 1489 1V [ �..a� !f