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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT �l 1601 E. HAZELTON AVE., STOCKTON, CA ! Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) ` (/j lle&) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This lication 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. .kc� Job Address O g City Ac Lot Size_31,0"c �0PM Owner's Name RR.XW U k �.AWNLE AJ Address Phone 3 Contractor_© Address Oyl License No. Phone —!)3.2 TYPE OF WELL/PUMP: NEW WELL-0,__ WELL REPLACEMENT ❑ DESTRUCTION ❑ -PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ \ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ; LJ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing i -*Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation 2Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type"of Pump H.P. State Work Done r- Well Destruction ❑ Well Diameter Sealing Material {top 501 , Depth = Filler Material lBelow 501 TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/AODITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is 44 "available within 200 feet.) Installation will serve: Residence Commercial_ Other Number of living units: ,.. Number of bedrooms _ Character of soil to! depth of 3 feet: Water table depth SEPTIC TANK Type/Mfg f Capacity No. Compartments PKG. TREATMENT PLT. ❑ it A00 Method of�Disposal � Distance to nearest: Well Foundation 40Property Line - �p r LEACHING LINE No. & Length of linesIOO�CGC1 _Total length/size FILTER BED ❑ Distance to nearest: Well�' Foundation 500 _ Property Line - !�i SEEPAGE PITS A Depth 95' _Size 32>11 Number SUMPS ❑ Distance to nearest: Well ] Foundation �-�C Property Line a-5 f DISPOSAL PONDS ❑ r 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 Jaaquin 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, l shall not A 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 roust call for red i cti s. Complete drawing on reverse side. i. Signed itle: Date: w ' ,I9 FOR4DEPMENT USE ONLY Application Accepted by `� Date An Grout Inspection byDateutFinal Inspection by Date Additional Comments: 44 Qu , tilTV01 -4 ❑ Stk 466-6781 i I�369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all opie nvir ental Health Permit/Services 1601-E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 on FEE AMOUNT DUE AM INFO OUNT REMITTED RECEIVED BY DATE PERMIT•'NO, y /art 11 +£H 3-24(REV.1/957 EH,4-,M