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APPLICATION FOR PERMIT 3 l _ SAN JOAQUIN LOCAL.HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA 1 Telephone 12091 466-6781 y PERMIT EXPIRES 1 YEAR FROM DATE ISSUED {Complete in Triplicate) �� g Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the vriirk'�her irrdescribed. This application is l made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and M,,if,flPie%a§d RegJlations of the San Joaquin Local Health District. WELL ''/Y1r ZUd,, r J r Job Address Sifn SaYI �Gt 7 ttCQ55 Rd. �.Qf1c( 01 ��C� l2i '"3`'LG$r��e =F _` PM" _ City [:t i!{ i/V.�IfLfVlF1i /is�?^!caUaa.>r.a' I T;O,13OX 757 , 1C 1 po'l'l l f-t 5366 Phone _Eq l ��f • TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ er 1'' 1 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER X IV16Y1I�Clt'f n) We I I DISTANCE TO NEAREST: SEPTIC TANK NA SEWER LINES > DISPOSAL FLD. N1" PROP. LINE >50 FOUNDATION AGRICULTURE WELL NA OTHER WELL: "* ' PITS/SUMPS N� INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation -L' Dia. of Well Casing S- ❑ Domestic/Private Gravel Pack Q Tracy Type of Casing Pvc- Specifications M Public f_-] Other C1 Delta Depth of Grout Seal /50Type of Grout C� bt' I I Irrigation -7-zj 1�O Approx. Depth I I Eastern Surface Seal Installed by D r111!n _ i Repair Work Done ❑ Type'of Pump W.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material {top 501 Depth Filler Material Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION l I DESTRUCTION i I (No septic system permitted if public sewer is ] available within 200 feet.) Installation will serve: Residence_ Commercial _ Other Number of living units_: l Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg 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 FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS L7 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ n 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 rules and regulations of the San Joaquin Local Health Di§trict. 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,I shall employ persons subject to workman's compensa- tion laws of California. The applicant must call for all required inspections. Complete drawing an reverse sidye..,,� Signed X �r I C. �'•"'-^ /�. 6, Title. C`"'`^'s fir 1 7��Date Q 2z FOR DEPARTMENT USE ONLY - iLo Application Accepted by , �� 4 Date r, Area �J� I Final Ins G Date Pit or Grout Inspection by to Inspection by i Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369.3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 y ! Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., PO. Box 2009, Stk., CA 95241 dy�� (1)Ap camp is N&tL, l3eUfAa Co.,; off_ �s s 9 _s'r`� t - CO FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE Puimrr r!O. �JII FFyO(,�� /f} CASH p iq �rj('��..EH13.24fREV.iin51 "l/ o O � t �� " r6 EH 14.26 t