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s APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRESA1 YEAR FROM DATE ISSUED (Complete in Triplicate), Application is hereby made to the San Joaquin Local Health District for a permit to construct andlor 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 � City � h Lot Size _7 PM `-" Owner's Name D6 A 5I� t- \" Address L/-( -' d�� Phone7_93 __7 Contractor ` r Imo.-� Address IeL - 2S -"'t\1`Li_ns'e'No. o vZ_Phone- =�- TYPE OF WELL/PUMP: ` NEW WELL ❑ - WELL REPLACEMENT ❑ DESTRUCTION ❑ r PUMP INSTALLATION ❑ SYSTEM.REPAIR ❑ OTHER ❑ DISTANCE.TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION.-� AGRICULTURE WE OTHER WELL PITS/SUMPS t INTENDED USE TY E OF WELLS PROBLEM AREA C TRUCTION SPECIFICATIONS Sy �❑ Industrial f;�-' ❑OphBo Manteca-It. Dia":wof Well Excavation Dia. of Well Casing Cl'DomestOPrivatfe \�)10 0Gravel Pack'j ❑ Trac R Type of Casing Specifications ( ,i❑ Public �❑ Other_ ""'� elta r , epth of Grout Seal '.Type of Grout Q i ❑ Irrigation ��. 4 Approx. Depth ID7Eastem Surfac -Seal Installed by' Repair Work Done ❑. Type of Pump }H.P.' Y� - State Work bone 'Well Destruction ❑ Well Diameter Sealing_Material Itop 50') i i'i vim] i ,Depth _Filler Material /Below 50') TYPE OF OF SEPTIC WORK: '�.NEW INSTALLATION REPAIR/ADDITION, ' DESTRUCTION ❑ INo septic system permitted if public sewer is available-within-200 feet.) { p Installation.will serve: Residence Commercial_ +'Other t Number of*li ng units:'` Numberiof_bedr9oms:' " f 1 I y i Character of sail to a depth of 3 feet: *� _ �' t Water table depth -^- SEPI�,IC TANK ; �' Type/Mfg �, f ,� `� Capacity "j*l Q G No. Compartments' v i �. PKG. TREATIVIENT PLT. ❑ * 6o qi�--� Method of Disposal ; Distance to ne rest: Well_,�•/Foundations 1 D' PPoperty Line {, l LEACHING LINE 'No. & Length of-lines 4 - - Total length/size J FILTER BED ❑ ,Distance to nearest: Well0� 'yFoundationt2�..".� Property tine \SEEPAGE PITS CI Depth Size Numher SUMPS _ Distance-to nearest-, ""'Well 5n__ Foundation f Property Line DISPOSAL-PONDS-_ ❑ ' " ! � ' �`r " 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.f Home owner or licensed agent's signature certifies'the followingaL_ceftify that in 1he$erformance 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, 1 shall employ persons subject to workman's compensa- tion laws of California." The applicant must Aor all required inspections. Complete drawing on reverse side. Signed X L t � Title: 1 (jam. Date: �Y I FO D ARTMIENT USE ONLY "Application Accepted by �Date� Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ 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 CASH CK 0 RECEIVED BY-3 a L� / DATTE� PERMIT'�NNO. + EH T3-24(REV.1/85) : 00 /_J�� EH 14-28 L7 T C! // BBB"��