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I� I� I ' APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT �j 1601 E. HAZELTON AVE., STOCKTON, CA 4 Telephone 12091 466-6781 i; PERMIT EXPIRES 1 YEAR FROM DATE ISSUED i (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 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. Job Address Fey A/— 00.iC Z Z Z City R E .. Lot Size 1,41) + 46Ct`•S PM i� S/�/`1.e Phone 9.?/��3 7 Owner's Name ZZ f Address 'At J � , Contractor's Name �/ /��/�/6�'�5��-S License No. Phone 6 -16 TYPE OF WELLIPUMP: NEW WELL ❑ WELL REPLACEMENT*❑ DESTRUCTION Ela PUMP INSTALLATION El �SYSTEMAEPAIR ❑- `' - OTHER LI DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE Ij FOUNDATION AGRICULTURE WELL .. '� OTHER WELL` - SPITS/SUMPS f: 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 - E] Tracy Type of Casing Specifications t ❑ Public El Other El Delta Depth of Grout Seal Type of Grout ❑ Irrigations- --Approx. Depth i❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. _ State Work Done Well Destruction ❑ Well Diameter Sealing.Material [top 501 -s--- -�- -v-- ---�' -Depth - - Filler MaterialfBelow 'I -- - -- - f TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION ElINo septic system peimitted if public sewer is `� r II. available within 200 feet.) V Installation will serve: Residence Z Commercial_ Other - Number of living units: Number of bedrooms iCharacter of soil to a depth-of-3 feet:-�� /`9 Water table depth 466 SEPTIC TANK 29!�Type/Mfg / Capacity No, Compartments PKG. TREATMENT PLT. ❑ Method of Disposal I Distance to nearest: Well Foundation Property Line LEACHING LINE No. & Length of lines Orb TrI length/size 2Q I, FILTER BED ❑ 'Distance to nearest: Well/BD Foundation Property Line 7 � Ks I ;. ) SEEPAGE PITS Depth �J_ Size , Number ? I SUMPS s ❑ Distance to nearest: Well f � f � �� Foundation�f Property Line 2>- DISPOSAL PONDS ❑ l 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."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 sdbject to workman's compensa- ti6n laws of California." .L The-appik t call for all required ins tions. C mplete drawing on re ve e. " `r Signed Title: Date: i DEPART ME SE ONLY Application Accepted by wo ate �Area` rE Pit or Grout Inspection by Date `O Final Inspection by Date Additional Comments: ❑%Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 83546365 v u Applicant- Return all copies to: Environmental Health Permit/Services 1601.E..Hazelton Ave.,..P.O:Box 2009, Stk., CA 95201 rFEE CK it INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIY'N0, s !I + EH 13-24(REV.10153) EH 14 c.28 'i