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i� APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT /-�/v .243-09-v2( �I 1601 E. HAZE'_iON AVE., STOCKTON, CA r ,l Telephone (209) 466-6781 p $,2, r It PERMIT EXPIRES 1 YEAR FROM DATE ISSUED t s (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. + �® City Lot Size M Job Address 1 .S' Owner's Name AAAt4nAddress k�2 ` ��!'—"fir= Phone 5r� Contractor's Name �+L A4 t Vl 5��-e t '(cense No. 40� - Phon 9��a - xTYPE OF WELL-/PUMP: __-,-NEW-WELL -D - .._-._.WELL REPLAgEMENT.❑. DESTR0CTIO1N'❑. - .-- �� PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ !DISTANCE TO NEAREST: SEPTIC TANK — SEWER LINES I DISPOSAL FLD. PROP. LINE 11 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 1 �O Industrial ❑ Open Bottom 11 Manteca Dia. of Well Excavation Dia. of Well-Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy ,/Type of Casing R Specifications C2..- In _ .-I❑ Public ❑ Others - ❑ Delta }'� Depth of Grout Seal +- Type of Grout ., i❑ Irrigation �` _.24pprox. Depth ❑.Eastern/ Surface Seal Installed by 3 !Repair Work Done '❑Type of Pump H.P. xi State Work Done 1iwell Destruction � ❑L Well Diameter Sealing Material (top-50'1 l Depth � Fillet--Material (Below 501 � ' TYPE OF SEPTIC WORK: NEW INSTALLATION EPAIR/ADDITION=❑ DESTRUCTION El (No septic system permitted if public seweris Q available within 200 feet.) Installation will serve: R sidence Commercial Other # Number of living units: Number of.,bedre�o,o�ms � E { Character of soil to a depth of 3 feet: Ar&,)( i Water table depth I�SEPTIC TANK T e/Mfg 1L : Ca act y� d No. Compartments l� - Yp g p tY o t [� TKG. TREATMENT PLT. ❑ f r t ;-- -��.. t _:i._ ^'� ':Method of Dis osPI IN Distance to nearest: . Well Foundation } y.Property Line _ �y��jr II LEACHING LINE $r_No. & Length of lines _ p I, ,_ Total length/size r , I FILTER BED ❑ Distance to nearest: Well ' V Foundation Property Line i r E -+ I SEEPAGE PITS ❑ Depth Size x. - s Number I SUMPS �. 1-1Distanceto nearest: Well 1 : TFoundation .t-� Property-Line .,. DISPOSAL PONDS ❑ 1 - w f�'• P. I hereby certify that I have prepared this application and that the work will be do_a in accordance with SanJoaquin cdunty ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. ' I;Home owner or licensed agent's signature certifies the following: "I certify that in the perfdrmance 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-,hlring 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." 1 Th applicant pplicant ust cal for all required ins ctions. Complete drawing on reverse side. Signed ., Title: Rate: ---_ .FOR DEPARTMENT USE ONLY I ( _ , . , I Application Accepted by �- �''�"��-_- Date ^� Area /3 4)11 Pit or Grout Inspecthon by Date Final Inspectio y Date + 'p l* ) E � G O ;_.f'orr-G�YA>K " Additional Comments: ' ❑ Stk 466-6781 ❑ Lodi 369-3621 anteca`p 823-7104 1 ❑ Tracy 835-6385 (4,Q1 Applicant- Return all copies to: Environmental QIthTPermit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk`; FEE AMOUNT DUE AMOUNT REMITTED CIC RECEIVED BY DATE PERMIT'INO. INFO CASH +EH 13-24(REV.10/831 EH W26 ,�13 i� $ 6L,- S •. d e - . , r �•� ii � i