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t APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601"E. HAZEL T ON AVE., STOCKTON, CA i Telephone (209) 466-6781 t 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 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 I Local Health District. w Job Address G)/ J ( ^_ City Lot Size . /- d Ri,_ PM Owner's Name 17 Address _ a - _ Phone mnRr o ¢�cav�n Contractor Address License No.210:a?�phone 9 TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT F-1DESTRUCTION L1 PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES � DISPOSAL FLD PROP. LINE FOUNDATION Jj2Q — AGRICULTURE WELL 42OU OTHER WELLA-kas�Pr. PITS/SUMPS / t INTENDED USE TYPE OF 1NELL PROBLEM AREA CONSTRUGTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing t0`s *Domestic/Private Grave! Pack ❑ Tracy Type of Casing Specifications I"1 Public F1 der , F Delta Depth of Grout Seal �i/`�PType of Grout 77 I f Irrigation y fir?&'Approx. De th I I Eastern tSutfaca Seal Installed by Repair Work Done Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') " Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ['I REPAIR/ADDITION I I DESTRUCTION I I (No Septic system 4 N I R y permitted it public sewer is ' available within 200 feet.) Installation will serve: Residence= Commercial_ Other Number of living units: , Number of bedrooms f Character of soil to a depth of 3 feet: I Water table depth ' SEPTIC TANK ❑ Type/Mfg i Capacity No. Compartments PKG, TREATMENT PLT, ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE �❑ No. & Length of lines Total length/size FfLTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS l I Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line 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, sta41aws, andrules and regulations of the San Joaquin Local Health 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 issueemploy any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contractingsgnature 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." The applican st call or all required inspec -ons. Complete rawing an rse side. Signed X f Title: Date:F ' FOR DEPARTMENT USE ONLY Application Accepted by Date Area 1 Pito rout spection by pat //Q %yLG Final Inspection by Date.lL Additional Comments: i ❑ Stk 466-6781 ❑ Lodi 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 4 FEE AMOUNT DUE AMOUNT REMITTEDRECEIVED BY } INFO -CATH DATE PERMIT'NO. I ..EH 3-24(REV,iix s)14- S. — i ts0 •414 smEH p ' d