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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE;ION AVE.; STOCKTON, CA Telephone (209) 466-67,91 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED • :3von .'"k .: " . :: , w(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. 1662 for well/pump and the Rules and Regulations of the San Joaquin Local Health District_, ttc3f. .. [ Job Address �T T�� J'�. y'/�v��r9P- city �r Lot Size PM i' Owner's Name -zZa. Address � L/ Phone �/a Contractor Address �. _ License No. Phone S TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST:_SEPTIC TANK_ SEWER-LINES DISPOSAL FLD. PROP. LINE Ii� I FOUNDATION -----L';,,AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ; [ ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing F-1 Domestic/Private; 171Gravel Pack ❑ Tracy i y ,Type of Casing I Specifications ❑ Public ❑ Other r p Delta i Depth of Grout Seal f Type of Grout ❑ Irrigation ----Approx. Depth, 'd Eastern`�urface Seal Installed by Repair Work'Done y❑ Type of_Pump 11 H:P`.E1'• State Work Done_ Wel] Destruction { Well Diameter r. Sealing Material (top 50') + Depth „•,� ..- f�f Fillei,.Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) / f `;Installation will serve: Residence-� Commercial_- Other -r-/ Number of living units: r� �Number,of bedrooms, PIP j ''- Character_of-soil to a depth'of 34eet:- '' f Water table depth 28Q f E ! SEPTIC ANKH # ❑ Type/Mfg r' } Capaciry�a d0 No. Compartments PKG..TREA�T++M��ENT PLT- ❑ _ Method of 4 ; %, f Disposal Distance to nearest: Well Foundation._ _ Property Line LEACHINGrLCNE No. & Length of lines �d f a =,_ Total length/size l FILTER BE{[) t El Distance o nearest: Well Foundati�ozn ] Property Line `fid „ SEEPAGE PITS El Depth X/.R„X/�. Size �3 -' Number SUMPS i K Distance'to nearest: Well 1u�_l� Foundation _,.._ Property Line 2.0_-___� DISPOSAL PdND$ ❑ 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. I 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 person in such manner as to become subject to workman's compensation laws of California.”Contractor's hiring or subcontracting 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." i The applica tmus�1111ffor llrequired ins tions. Complete dr wing on reverse side. Signed ) Title: el�V T Date: VFOI DEPARTMENT USE ONLY Applica�t'e�Accepted by ,�/ Date-- Area...,• C> Pit or ro-1(' Tut ns c y + � Y Date Final Inspection by (•'��''pat, Additional Comments�� +�� Q�-.>�� 1�Jl�s� ,- %-Vn A ❑ Stk 466-6781 Lodi 369-3621 ❑ ;Manteca 823-7104 ❑ Tracy 635.6385 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 C K 0 RECEIVED BY DATE PERMIT''NO. + EH 13-241REV.UtiW '7D Irk -7r-A- ,EH 10.28 �J ^S�