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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE:T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR 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. Z Job Address City Lot Size PM Owner's Name ��" Address#- „ �.s i� y�' A sy Phone ~ Contractor/ s License No. / W f Ii Phone`r lF~ Addres } TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ k PUMP INSTALLATION ❑ C EPAIR ❑ OTHER ❑ f DISTANCE TO NEAREST: SEPTIC TANK SEWER IDISPOSAL FLD. PROP. LINE } FOUNDATION AGRICULOTHER WELL PITS/SUMPS E INTENDED USE 'TYPE OFWELLPflOBt EM AREATI0 SPECIFICATIONS tt❑ Industrial ❑ Open Bottom ❑ Manteca Excavation4 �` `�� Dia. of WeII;Casing ❑ Domestic!Private ❑ Gravel Pack ❑ Tracy ing Specifications I'1 Public F Other" �' '❑ Delta eput Seal Type of Grout IX I I Irrigation ---Approx. Depth I ! Eastern # Surface Seal Installed by Repair Work Done 13 Type of Pump H.P. . State Work Done ' t S Well Destruction ❑ Well Diameter A Sealing Material [top 501 Depth Filler Material (Below 50.1 TYPE OF SEPTIC WORK: NEW INSTALLATION l REPAIR/AD ION I 1 DE5 RUCT[ON I 1 Do septic system permitted if public sewer is vailable within 200 feet.) 1� K1 a Installation will serve: Residence --_ Commercial Number of living units: Number of bedrooms i Character of soil to a depth of 3 feet: + 1' Water table depth I� SEPTIC TANK I ❑,'Type/Mfg Capacity V.. No. Compartments r PKG. TREATMENT PLT. [IMethod of Disposal " 'T'-"'D&arice t6'nearest: WellI Q C,�- Foundation Property Line LEACHING LINE ❑ No. & Length of lines N TotW lengthlsize S s � e.s FILTER BED r.,0 Distanceito nearest-A Well Foundation f Property LineAvd 1 SEEPAGE PITS 1 1" Depth 2 -Size Number i SUMPS 0 Distance to nearest: Well ..._ Foundation 11 — Property Line j DISPOSAL PONDS O_ �►'~ s' 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 z _ rules and regulationslof the San Joaquin Local Health Di%trict. l 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 perctn in sucq#manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature , certifies the following: "I cgrtify 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 applican must`;all fora required i pections."Complete drawing on reverse side. ' i Signed X ~ { '" Title: I[k= AAn.9/Z i Date: -9. +L' OR PARTMEfVT USE ONLY R_a t Application Accepted by zi Date b`, Area Pi Grout Enspection by` Date 1-30-13`� Final Inspection by��6 - �A, ��.+a�"Date I Additional Comments: ❑ Stk 466-6761 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 635-5385 r Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 I FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT"N0. INFO C/ASH +.EH 13-24(REV.s i H 55 - . .,�.,„EH 14.26. - -