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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZETON AVE., STOCKTON, CA Telephone f209) 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. Fire vi Job Address '• r n22d City (_4mf _ Lot Size PM Owner's Name J 23 T 'r 1a Address /_ { Phone Contractor q � _ Address Road �icense No. �P --9S Phone TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT Ll DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK Md SEWER LINES- I Z.O1 + DISPOSAL FLD. PROP. LINE FOUNDATION 1 AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS r ❑ industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing (p 4,6omestic/Private Gravel Pack ❑ Tracy Type of Casing Re 1 Specifications F] Public wOOf Type of Grout f 1 Other ❑ Delta Depth of Grout Seal f I I Irrigation d pprox. Depth l I-Eastern S rface Seal Installed by i I Rep 4air Work Done ❑ Type of Pump 5U bPj-_ H.P. _, 2 _ State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 50') — TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION l I DESTRUCTION I 1 (No septic system permitted if public sewer is t available within 200 feet.] Installationwill serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms '4Gharacter of soil to a depth of 3 feet: tea;• Water table depth `_SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments r PKG. TREATMENT PLT. ❑ c ]..:Method of Disposal Distance to nearest: Well ' foundation Property Line LEACHING LINE ❑ No. & Length of lines• 1 Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS l I Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I herQby 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 tnd regulations of the San Joaquin Local Health District. Home, weer or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shat!not emplo'' 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•iwthwperformance-of-the-work-for•which-this-permit�is•issued,I-sha11•employ,personssubjecYto workman's compensa- tion law of Californ' The applican m t call for all requi inspec ns. Com late d Ing on reverse side. " L Signed X Title: Date: FOR DEPARTM NT USE ONLY Application Accepted by ' Date ex ea Pit v rout spection by Dat e�� Final Inspection by Date,-"AO Additional Comments: Ora' �� fair = �� •�'T/•? 1.��9'A �/��?Q ��'s�� o �c.'E�i� ❑ Stk 466-6781 ❑ odi 369-3621 ❑ Manteca 823-7 04 ❑ Tracy 835-638 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 t - v FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. INFO ( 34/ CASH/} +.EH13-241REV.iix5f f3�1 � `QJ� ✓ EH 14-29