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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON ON AVE., STOCKTON, CA Telephone 12091 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED etc;-f�`zEQS CT -{Complete in Triplicate) lO 3 _ 2- 0 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 Local Health District. `J' �1�� San Joaquin Job Address f XA!,7771- TCity Lot Size pM Owner's Name �Dls /�� Cdr �Q r �'j� hone l Contractor ddress- License No. Z"/ —Phone TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION,, SYSTEM REPAIR ❑ OTHER I-]DISTANCE TO NEAREST: SEPTIC TANK 77 —r f SEWER LINES DISPOSAL FLO. =::!' P ��— FOUNDATION AGRICULTURE WELL �� OTHER WELL � LINE PROP.ROP. LINE INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS UMPS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation- Dia. of Well Casing A Domestic/Private kGravel Pack ❑ Tracy Type of Casing Specifications M Public Ll Other n Delta Depth of Grout Seal _ �e � Type of Grout .�_ . f I irrigationApprox. Depth 1 1 Eastern Surface Seal Installed Repair Work Done ❑ Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material (top 501 A Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION f 1 DESTRUCTION I 1 INo septic system permitted if public sewer is Installation will serve: Residence— Commercial— Other available within 200 feet? Number of living units: 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.❑11 Method of Disposal Distance to nearest: Well Foundation Property Line r LEACHING LINE 0 No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line ' SEEPAGE PITS 11 Depth Size Number SUMPS 0 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, state laws, and rules and regulations of the San Joaquin Local Health District. i 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 1 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 applica u t all quir . Complete drawing on rev Prst3 side. Signed X Title: �z — Date: FO DEPARTMENT USE ONLY Application Accepted byDate A rea Zu_c) Pit or Grout Inspection by Date Final Inspection by_ &A E 2/- n ` _ / -�� Date � Additional Comments: l s'�S '� L l {� y ❑ Stk 466-6781 ❑ L di 369-3621 ❑ Manteca 823-7104 ❑ Trac56385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK INFO CASH RECEIVED 9y BATE ENO. +.EH 1C)3-241REV.r/N5) //EH 14-2a �