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i APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA ip Telephone (209) 466-6781 - PERMIT EXPIRES 1 YEAR FROM DATE ISSUED } o et Triplicate) � � .. _ (C mpl ezin „"a 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 C/ il' Cit Lot Size _ y P M Owner's Name O Address r Phone �Rrfe' '�, F Vontract r Address-2f�0 �/ 1 Gid X.XA 4 License No. Phone /�� •"�j� TYPE OF WELL/PUMP: NEW WELL,, WELL REPLACEMENT DESTRUCTION ❑ PUMP INSTALLATION Q SYSTEM REPAIR ❑ OTHER ❑ ,1 DISTANCE TO NEAREST: SEPTIC TANK: SEWER LINES. DISPOSAL FLD. PROP. LINE a . - --.�...._...-,- -_-.-y_...._--c FOUNDATION AGRICULTURE WELL OTHER WELL �` PITS/SUMPS INTENDED USE 11 TYPE OF WELL PROBLEM AREA CONS RUCTION SPECIFICATIONS 47� ❑ Industrial 0 Open Bottom ❑ Manteca Dia. of Well excavation ia._ofvWell Casing � 3 Domestic/Private Gravel Pac� ❑ Tracy Type ofiCasing 1 ed Specifications ! ,❑ Public ©r Other ❑ Delta Depth o Grout Seal s� f Type of,Grow&�-roO Ab r Aq Oylrrigation #�4pp�ox. Depth ❑ Eastern Surface Seal_flnstalled by AL /�T "� Repair Work Done ❑ T#ype f,PumH.P; -rs• I State Work Done k 5f t 1 W.eil'Destruction ❑ We1l,biameter Sealing;MateIial {top 50'1 r Depth Filler Material_IBelow-'1 - -- - ';TYP-E,OF SEPTIC WORK: lNEK INSTALLATION ❑ REPAIR/ADDITION ❑ El (No septic system permitted if public sewer is j r ~10 available within 200 feet.) 6 Installation will serve: Residence— Commercial_ Other umber of living units: + s Number of bedrooms 4 x Character bf soil to a depth-&3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Iy�� Capacity r �{ No. Compartments j I� PKG. TREATMENT PLT. ❑ I� i 1 Method of Disposal Distance to nearest: Well Foundation .. Property Line e -CEACH*M`r1NE El . No. & Length of fi es — l Total length-/size � 1 FILTER BED - EJ . Distance to nearesWell r` Foundation �-" ipertyg-Line i SEEPAGE PITS ❑ ' Depth 7 Size i�"��' Number + ) h SUMPS El, Distance to nearest:-� Well ' Found ty�ori Prollerty Line DISPOSAL PONDS ❑ ) I hereby certify that I have prepared this application and that the work will be done i� accordance with_San Joaquin county orcin)nces,-_state'.laws, and rules and regulations of the San Joaquin Local Health District. .o V° '� 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;l shall-not 1 'cofit ilf n'g`s i\ v e 7 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." 4� t 1 } -- • , c t.� I L y^:1 �JRa Y The appGca ca or ed,inspections Complete drawing o reverse side. Signed Xri� . T Title: OI�/lRf�� o ;�� FOR DEP A TMENT USE ONLY ,( Application Accepted by Date U �� Area v f�y Pit or Grout Inspe tion by Date Final Inspection by d� ell :w Additional Comments: L _ i%-r c--- ❑ Stk 466-6781 ❑ Lgdi�j: 369-3621 EDManteci -fk2l-7104 i' ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 '?n !� , INFO- +AMOUNT.DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. + EH 13-241pEV.tins7 ` O � . EH 1428 T -, .- __ • - _ ., ., r �/a/i 1¢a —�� 3