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4OG 7 APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAT 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. ip Job Address � � ! City C e PM e! o y1 S e YC ✓ Owner's Name e, Address 1/01 jy ea /, !ZO hone M'3 a s V , 74/1k ContractorkALR Address Q License No.t62313—Phone TYPE OF WELL-/PUMP: I� NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ae 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 /f F ❑ Ind strial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation fDia. of Well Casing Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing �' Specifications f'l Public [-1 Other ❑ Delta Depth of Grout Seal Type of Grout _ I I Irrigation 'i.Approx. Depth I 1 E stern Surface Seal Installed by_- e - Repair Work Done Type of Pump H.P._ State Work Done to 50' `} 4 Well Destruction El Diameter Sealing Material I p. 1 Depth Filler Material (Bel w 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I'I REPAIR/ADDITION I I DESTRUCTION i I (No septic system permitted if public sewer is 1 available within 200 feet.l 1 Installation will sere �ence_ Commercial �Oth " z Number of living units: II Num ooms f` Character of soil to a depth of 3-feet: �" `._� Water table depth SEPTIC TANK ElTypel.Mfg a �ry� No, Compartments 4' PKG. TREATMENT PL'T:{] I d of Disposal $ Distance to nearest: Well Foundation Property Line LEAGHING'LLIINE ❑ No. & Length of lines Total length/size f FILTER-BED 0 Distance to nearest: Well Foundation Property Line � t SEEPAGE PITS I i Depth Size Number .SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ IN' hereby ce a ave prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules an regulations of tie San Joaquin Local Health District. t` ,, HoKif-ieY.'the wner or licensed ag is signature certifies the following: "I certify that in the performance offthe work for which this.permit is issued, 1 shall not emny person in such nner as to comesvb' to workman's compensation laws of California." Contractor's hiring or sub-contracting signature c loll ing: "I cu that i rf rm ce f the work for which this permit is i" ued, I shall employ persons subject to workman's compensa- te n laws of Cali T e applica t t t ail re r Comply a drawingeb' rev de Sig X �7itle Date: V .�� I, FOR`DEPARZME- T,USE ONLY Application Accepted by Date Area Pit or Grout Inspection by Date Final Inspection by ` ' _ Date I Additional Comments: t r ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy'835-6385 Applicant - Return all copies io: Environmental Health Permit/Services 1601 E. HazeltonEAve., P.O. Box 2009, Stk., CA 95201 P FEE kNFO AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT"NO.CASH�}i + SH 1 3-24(REV,1in5r EH 1426 1 I�.