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i fi 6 CVU PPLICATION FOR PERMIT � SAN JOAQUIN LOCAL HEALTH DISTRICT F 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 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.THs application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rgles and Regulations of the San Joaquin Local Health District. ''• Job Address Oil e CJ�d K7 *N S Lo lzek t PM r e { Owner's Name j Address f� 1��/� /CPhone CVIFafc�/f�"" T1`P.� t!b ` S�ddress ~��{��1 License No �Phone TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ e• _ .+v .� PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK OO. .SEWER LINES in DISPOSAL FLD. PROP. LINE 410, FOUNDATION -'s-1 t. ;AGRICULTURE YELL OTHER WELL PITS/SUMPS ZOO'_r II/ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open'Bottom t „�l❑ Manteca Dia. of Well Excavation Dia. of Well Casing I Domestic/Private El Gravel.Pack .❑ Tracy Type of Casing atSpecifications r f 17 Public i a++ ❑ Other j, F, 11❑ Delta Depth of Grout Seal7��- Type of Grout Ll Irrigation- = ppioz. bepth;:�❑ Eastern Surface Seal Installed by .S nee Repair Work Done ❑ Type of Pump • H.P, State Work Done N Well Destruction ❑ Well Diameter Sealing Material (top 50') r3 ► Depth yr Filler Material (Below 501 ga. r � . TYPE OF SEPTIC.WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence= Commercial_ Other llrll) Number of living units: , �i_� Number of bedrooms - Character of soil to a depth of 3 feet: { Water table depth ; SEPTIC TANK .t ❑ , Typ"e/Mfg Capacity No. Compartments a p� PKG. TREATMENT P-L'T. ❑ Method of Disposal i = r Disnce€to nearest: Well �.oundatiori Property Line t h f -LEACHING LINE ❑ w No:A Lengthoflines Total length/size t' i FILTER BED ❑ • Distance to nearest: Well FoundationProperty Line ' Illls y _ - e SEEPAGE PITS % ❑ Depth Size - x 'Number' SUMPS ❑ Distance'to nearest: Well Foundation Property,Lin`e f DISPOSAL PONDS ❑ , I hereby certify that I have prepared'this application and that the work will'be done 6,`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 wofkman'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 whh th icis permit is issued, I shall employ persons subject to workman's compensa- tion laws of California,"" r l 4`A y The applicant must call, r- II ired inspections. Complete drawing oq r erse Sid `y4 w/ivl a Signed Title: Dat tS S FOR DEPAR MENT USE'ONLY Application Accepted by1 -^- 'k _ `Date-""'� r Area - q Pit or Grout Ins action b J S id P Y Date Li Final Inspection by Date i r Additional Comments:--l.-- _ �d - - i ❑ Stk 466-6781 E3 Lodi 369-3621 C) Manteca 823-7104 ❑ Tracy 835-6385 f Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk.,CA 95201 FEE I INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT`NO. + EH 13-24(REV.f/Hsi -�/�5) --fig �•33 EH 14-26 . O ..7 _ ,,,.