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APPLICATION 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. 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. �] /� �j yAY�! ��yr� Job Address /S-772 / r'C'SCOzz' `l1 City r /ans-i C�Lot Size / PM Owner's Name J6l 77 DI J9-JP— Address 5,Q7Ve_ 924 Phone u 3 — / Contraclor(TUi C�El�1191_1 Address/op D, 40 /-/W cense No. 926'-3 Phone5"nt?—S4 Z3 TYPE OF WELL/PUMP: NEW WELL 91 WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION C1 SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK 4Q= SEWER LINE„WLDISPOSAL FLD4?432 + PROP. LINE 63 FOUNDATION AGRICULTURE WELL —OTHER WELL c32/ PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ?L Manteca Dia. of Well Excavation // Dia. of Well Casin Domestic/Private A Gravel Pack ❑ Tracy YP of Casin9V � Specifications Type 11 Public H�Cyl Other Cl Delta Depth of Grout Seal Typo of Grout/1� i' � I i Irrigation �-YApprox, Depth l 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 Depth Filler Material (Below 501 _ TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION l I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet-) Installation will serve: Residence_ Commercial— Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS i I Depth Size _ Number SUMPS Cl Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ rr__ 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.” 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- n tion laws of California." `s The applicant m st call for all required in pections. Complete drawing on reverse side. Signed X4dd5d1 Title: �� C�D�' Date: OR DEPARTMENT USE ONLY _ Application Accepted by 'j m°f Date f y r�� Area Pit or ou Inspection by Date, 4 Final Inspection by i- Date Additional Comments: / C7 Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca -7104 ❑ Tracy 5-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Sik., CA 95241 FEE INFO AMOUNT D/UyE� pAMOUNT REMITTED CASH RECEIVED BY DATE PERMIT-NO. ♦ EH 13-24(REV.tia5) EH 14-26