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` APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR 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 l made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for welUpump and the Rules and Regulations of the San Joaquin k Local Health District. Job Address 236 0 • [� B Ci� rS City 4l Lot Size PM Owner's Name J da� Address X3 60 W K Phone -?qy, Contractor lr Q Address 12-fy #441 License No.3�� Phone 3649 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION)D--------------`"SYSTEM-'REPAIR-C3 OTHER ❑ r i DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE fFOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ! ❑ Industrial 1, ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications: ii`i Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout I ] Irrigation - _._Approx. Depth I I Eastern Surface Seal Installed by i �] Repair Work Done ❑ Type of Pump H,P, State Work Done_ 1 t 1 Well Destruction ❑ Well Diameter Sealing Material Itop 50'1 F § Depth Filler Material (Below 50') I C —� TYPE OF SEPTIC WORK: NEW INSTALLATION E REPAIRIADDITION i I DESTRUCTION I I (No septic system permitted if public sewer is { 3 available within 200 feet.) < Installation will serve: Re idence ✓ Commercial Other {^ k J Number of living units: Number of edrooms� 1 I I Character of soil to a depth of 3 feet: Water table depth a ► SEPTIC TANK &KTypelMfg Capacity�a1�- No: Compartments I PKG. TREATMENT PLT, ❑ I IU Mkt ddd of Disposal a Distance to nearest: Well Foundations -7 ^M pPropely Line .2-00 f I , , � ,ref a ' v.# LEACHING LINE P,--No. & Length of lines Teo—t�a-llerngth/size a j FILTER BED ❑ Distance to nearest: WdF Foundation s Property Line SEEPAGE PITS L-K Depth �' r Size i l Aumber'S. 73 SUMPS ❑ Distance to nearest: Well Founc6tion ,Z Property Line.� DISPOSAL PONDS ❑ � ' I hereby certify that I have prepared this application and that the Work w Il he done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health Di§trict. / I/ I Home owner'or licensed agent's signature certifies the following: "1 ertify that in the performance of the work for which this permit is issued, I shall not i 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 wkch=this permit is issued,k shall employ persons subject to workman's compensa,.- p1tion laws of California." z i f ) E it The applicant- us call for a ^required inspections. Complete drawiiig on reverse side. 1 i s 3. h 1 Signed X Date: I FOR DEPARTMENT USE ONLY Application Accepted by Date - ' W Area 1 L it r Grout Inspection by Date Final Inspection b� pat Additional Comments: i i ❑ Stk 466-6781 ❑ Lod 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 I INFO AMOUNT DUE AI4A`O�UNT,JREMkTTED y-CASH CK RECEIVED BY DATE PERMIITT�N]O. f-EH 13-24{REV.$/H51 ,[/. ,(f r-(/� r��, / y{ ,� �� '-f•{ II I