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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL ION AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1'YEAR FROM DATE ISSUED (Complete in Triplicate) 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 and Regulations of the San Joaquin Local Health district. /�/� �p Job Address lyyoui/ /I� /e0 - — City Lot Size PM i Owner's Name �,_X-4 � Address � ?hone 7 Contract e-h Address f 6- / License No.;52 92-2C, PhoneJ d �f 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 �- FOUNDATION 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 ❑ Domestic/Private ElGravel Pack ElTracy Type of Casing Specifications 11 Public Cl Other n Delta ?:- Depth of Grout Seal T I ype of Grout III Irrigation --Approx. Depth ( I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done _ Well Destruction-` ❑ Well Diameter Sealing Material (top 50') Depth F}` Filler Material {Below 501 TYPE OF,SEPTIC WOAK; NEW INSTALLATION REPAIRIN15DITION 1.l DESTRUCTION I 1 (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: ResidenceCommercial':1— Other Number of living units:4_JL__ Number of b r oms _ F w, Character of soil to a depth'.of 3 leer Warer table depth (J t SEPTIC TANK f!� Type/Mfg r fCapacity 90 No. Compartments ' . PKG. TREATMENT PLT...0 , : Method of Disposals 1 " Distance to-nearest: W Foundation_ Property Line _.p e / 1`. L LEACHING LINEo. & Length-of-lines - o Total length/size FILTER BED-`---�--❑-"Distance'to nearest: r Well !0`0'U1Foundation_/O Property Line S-5-e F SEEPAGE PITS-F, I Depth,_s` .� Size_ Number ^' SUMPS T " "#ti❑Distance to nearest: Well Foundation 1C3 Property Line ;r- DISPOSAL PONDS ❑ I 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 i rules and regulations of the San Joaquin'Local Wealth District. 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 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 apps cant mus I'for all req din pections. Complete drawing on reverse side. Date: Signed X Title: � �d-�3 . ^� V FOR DEPARTMENT USE ONLY Application Accepted by Date �' Arai f Pi or Grout Inspection by Date ^ i J Final Insp ction'by+ Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 623-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REM ED CK RECEIVED BY DATE PERMIT NO, INFO CASH + EH1 3-24 IHEV.i/e 51 EH 14-28