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i APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1'YEAR FROM DATE ISSUED (Complete in Triplicate) Application is haieby 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. 548 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. / 1 `t Job Address �20 �' y s C_ ��` City "'D4 Lot Size PM �g11ewj �r �� klJ +fC��"K" *�,2uV PhoneC ly �3�"" 0 OQw`n3er�s Name Address bu 0 lentCO.pp00-Ur-A TX Contractor f i -. I Address F�- �[�Zb LzwcokA I C 4 License No 34"t'S PhoneOIII&49 35 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER W SPS) �c3r1N \ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL�MW PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation iA Dia. of Well Casing A ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing I4t3y1k, Specifications M Public Other t:i0rV"1r, ❑ Delta Depth of Grout Seal .2 d FT 9 e6SType of Grout I I Irrigation —.Approx. 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 50'I ISLi'l-JOAr fze— Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIRIADDITION LI DESTRUCTION.[ I (No septic system permitted if public sewer is J available within 200 feet.) Installation Cil erne: 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 anon Property Line LEACHING LINE 0 No. & Length of lines a length/size FILTER BED ❑ Distance to nearest: Well Foundation r t Pro Line SEEPAGE PITS I 1 Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 4— 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." 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- tion laws of California." The applicant must II for II requireo inspections. Complete drawing on reverse side. p Signed X r Title:_ srr� (2d2 fcsp. 4t_ Date: JV or f FOR DEPARTMENT USE ONLY t Application Accepted by I Date— � G��p�j � Area 7 �`� Pit or Grout Inspection by Date Z Final-Inspection by �G�' Date r Additional Comments: _ r ❑ Stk 466-6781 XLodi 369-3621 ❑ Manteca 923-7104 ❑ Tracy 835-6385 _,,._._....._. Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY DATE PERMIT NO. + EH 13-24(REV. /n 51p._ f/3 EH t4-26 V �` l