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P PPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE;_TON AVE., STOCKTON, CA ' Telephone {209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) �I .i 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 andReguIatioons'of the San Joaquin Local Health District. II! �© RJY®�Ip. /.Ji f City _S Liot Size PM. •Job Address _ i Owner's Name l�A.! Address ' T/�}I1ifs n II Phone r At ADeF4-/3c2�- License Noll ��'? Phone Contractor [3 � Address L TYPE OF WELLIPUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ i PUMP INSTALLATION L2SYSTEM REPAIR El OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELLIF PITSISUMPS ? INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS !! Dia. of Well Casing ❑ Industrial (7) Open Bottom El Manteca Dia. of Well Excavation w.. 1 Cl Domestic)Private ❑ Gravel Pack ❑ Tracy --Type of Casing Specifications FI Public f 1 Other Cl Delta Depth of Grout Seal Type of Grout - I 1 Irrigation __Approx. Depth I I Eastern Surface Seal Installed by 0 _ Repair Work Done C1Type of Pump H.P. State Work,Done_ l Well Destruction ❑ Well Diameter Sealing Material [top 501 Depth _ Filler Material 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION I REPAIRlADDITI l ESTRUCTION I 1 INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial_ Other Number of hying units: -__I— Number of bedrooms II Character of soil to a depth of 3 feet: °(�J-- Water table depth SEPTIC TANK L3Type/Mfg 0.0-A&P--ems "� � ' � Capacity I,No. Compartments PKG, TREATMENT PLT. ❑ , rp Al )04-4 GG lWethod of Disposal +� f 5, stance to nearest: Well Foundation Property Line- II a LEACHING DINE W No. & Length of lines Z � r Total length/size ' 'f- �01 n QU Foundation Property.Line 2G1 1 to nearest: WeII_..L— _ C ❑ Distance FILTER BED .r --, . « -"y T,,_ -- i 11 lo f _ y SEEPAGE PITS Depth : Size �� _ _ Number ` SUMPS ? ❑ Distance totnearest: Well Foundation — Property Line" %d _� t DISPOSAL PONDS ❑ 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 3 rules and regulations of the San Joaquin Local Health District. �r r 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 tie"come 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,'I shall employ persons subject to workman's compensa- tion laws of California." u �� The applicant must call for allrequired inspections. omplate drawing on!re`versesido. Signed X�� Title: I� "Date: //"3- r7. OR DEPARTMENT USE ONLY ' :mss 3 �Q' (J -.7 Area / Ap lication Accepted by Date IIS Y Pit r Grout Inspection by ate 7 Final In3pection by �� Date -< ep o;ti Additional Comments: � � � /v+� ❑ Stk 466-6781 Lodi 369-3 1 anteca 823-7104 ❑ Ttacy 635-6385 I (fl Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., f.0. Boli 2009, Stk., CA 95201 INFO AMOUNT DUE AMOUNT REMITTED 17 O SH lc�xRECEIVED BY DATE - PERMIT'NO. + EH 13-241REV,r/n57 /� , 5 r � //`✓� / i- ` EH 14-26 II