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S APPLICATION FOR PERMIT ' i SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephohe (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. Job Address AV 04> City G Lot Size PM Owner's Name JrClpkV U-PAE Address Phone Contractor /Q s z/ Fiza z Address +c l� License Nor1_ZQ52W__._Phone_ �- TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ i PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK- SEWER LINES DISPOSAL FLD. PROP. LINE_ _ FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS —a-Industrial—- -- Q Open-Bottom—0•Manteca-�.Dia.-of Well_Excavation �__ -_Oia. of.-Well•Cesing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications F1 Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout` I I IrrigationApprox. Depth 1 I Eastern Surface Seal Installed by - Repair Work Done 11Type of Pump H.P. State Work Done— k Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIRIADDITION l I DESTRUCTION l I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence 010� Commercial_ Other + Number of living units: Number of bedrooms_ r Mater table depth Character of soil to a depth of 3 feet: p SEPTIC TANK ❑ Type/Mfg L Capacity JNo. Compartments r ' PKG. TREATMENT PLT. ❑ "° . �.h Method of Disposal 3 r Distance to nearest: Well /Foundation Cry_ Property Line �1�] � I ' LEACHING LINE No. & Length of lines o�—low is _ Total length/size :20'% P' I 111V1% tlrT :. iiii . - s p FILTER BED ❑ Distance to nearest: ell� f_ Foundatio_n Pp roterty tine, t w I,, 4 SEEPAGE PITS,� I I Depth �d r�' Size_ yT� Number' S�f — 1I SUMPS. ,� ( "Distance to nearest: Well/�s!_ Foandation�ayf/ Property Line DISPOSAL PONDS ❑ I hereby certifyrthavl have prepared this application and that the work will be done in accordance with Sats Joa loin county ordinances, state laws, and rules and regulations oiohe.San-Joaquin-Local Health District. _ ' a Home owner or licensed agent's signature certifies the following- 1certify that in the performance of the work for which this permii is issued, I shall not employ any person in such manner as-to become subject to workman's compensatior6aws of California." Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance bf_the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California. + t The applicant must call"f ;all required inspections. Complete drawing on reverse side. + Signed X Title: =-�/J Date: :��'��'$� :fORDEPARTMENT USE ONLY i s r Application Accepted by 5 Date �� Atea � tl Pit or Grout Inspection by Date Final Inspection by ate 30 t " Additional Comments: 1 i ❑ Stk !466-6781 ❑ Lodi_369-3621 . .. ❑ Manteca-.•823-7104. ❑-Tracy 835-6385 - Applicant - Return all copies to.,Environmental.Health Permit/Services 4601_E. Hazelton Ave., P.O. Box 2009, Stk.,'EA,95201 71"1 r 3 FEE AMOUNT DUE AMOUNT REMITTED CK GASH RECEIVED BY DATE PERMIT'.NO. I4 INFO EH 13.24 1REV.i i H 5Y • EK 14-26 (J I