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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE.,,STOCKTON, CA N t Telephone {209} 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) R 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. I -. 0 I!z r F Job Address . .�.,.., .., ,. •r:. -� Cit y5 t O C Lot Size PM Own*'sName V.Prn PPI.QZ - Address 1230 "SChool .Street- " Phone 941-2605 Contractor_Wi l l igms Plumbi0-gAddress 2360 N . Wi159_ Wa License No. 289293 Phone 466-4004 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR;❑' OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES I �-- DISPOSAL FLD. PROP. LINE j F _ ;FOUNDATION AGRICULTURE WELL I OTHER WELL PITS/SUMPS INTENDED USE ' ,,"TYPE OF WELL PROBLEM AREA CONSTRUCTION SPEC'IFIC`ATIONS ❑ Industrial ❑ Open Bottom El Manteca—Dia. of Well Excavation Dia. of Well Casing C1Domestic/Private l ❑ Gravel Pack i ❑,Tracy Type of Casin ❑ Public ❑ Other g Specifications O Delta Depth of Grout Seal ❑ Irrigation ► Type of Grout ----Approx. DeptFi; ':Q Eastern Surface Seal Installed by Repair Work Done` LJ Type of Pump H.P. State Work Done_ Well Destruction ' ❑ -Well Diameter 'v Sealing Material (top 50') E l Depth i p Filler Material (Below 50') ± J- 1 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION CJ DESTRUCTION %i No septic system permitted if public sewer is i 1 available within 200 feet.) t Installation will serve Residence Commercial i Other 3 b Number of living uni[s: Number of bedrooms a 1 l Character of soil to a depth of 3 feet: : Water table depth SEPTIC TANK1 ❑ Type/Mfg Capacity No. Compartments t I� + PKG. TREATMENT PLT. ❑ " w Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size / , FILTER BED ❑ Distance t k nearest: :i Well Foundation s * __ III«</// Property Line $ �1 SEEPAGE PITS ❑ Depth LSize r Number SUMPS I] Distance to nearest: WellFoundation Pro DISPOSAL PONDS p b -Property Line 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: employ - "I certify that in the performance of the work for which this permit is issued, I.shall not p Y an y person in such'manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signatufe certifies the following: 'hcertify 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.' l d The applicant must call for all requi ed inspections. Complete drawing on reverse side. Signed / r I Title: ' Date: e, I F FORR_T_MENT USE ONLY K 1 Application Accepted by Date Area ► Pit or Grout Inspectionby M Date Final Inspection by Date Additional Comments: ❑ 5tk. 466-678110Lodi 369-)621, C3 Manteca 823-7104 ❑ Tracy 835-6385 1 l Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.G"jBax 2009, Stk., CA 952{11 FEE INFO �•")rAMOUNT DUE AMOUNT REMITTED CK. RECEIVED 6Y �~ ] DATE PERMIT NO. + EH 13-24(REV.t i R 51 V[7 . _ W� 4-[v},� "o-�,. ( ^'�_. �+ /�EH 14-28 K?-�� 33 }} V + V — ✓ V ] $�2-1�`{