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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA f Telephone (209) 466-6781 E PERMIT EXPIRES TYEAR FROM DATE ISSUED r i (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. ` t Job Address 9 y 33 Q Cit00011, Lat Size PM Owner's Name e 10 AA OL _ Address 190 V 7!SI �14 I Phone Contractor(94` Address S7i�C12 0L License No. 30'317N Phone) a gF33"y TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 0 DESTRUCTION ❑ ' PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Q\ 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 0 Gravel Pack ❑ Tracy Type of Casing Specifications F1 Public t ❑ Other F1 Delta Depth of Grout Seal Type of Grout _ I I Irrigation _.Approxi Depth- . I I Eastern ..Surface Seal Installed by Repair Work Done ❑ Type.`of Pump H.P, 3 State Work Done_ Q Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material lBelow 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I] REPAIR/ADDITION4d' DESTRUCTION I I (No septic system permitted if public sewer is � available within 200 feet.) Installation will serve: Residence J Commercial O`er t �l Number of living units: Number.of`bedrooms Character of soil to a depth of 3"feet: 3,944 L'-,i" Water table depth Y SEPTIC TANK £❑ Type/Mfg Capacity No. Compartments s PKG__T.REATMENT PLT. ❑ Method of Disposal tf Distance to nearest: Well Foundation Property Line LEACHING LINE Gl`No. & Length of lines `� 'OQ _ M Notal length/size JW FILTER BED ❑ Distance Ito nearest: Well Foundation- Property Line �� ------ - SEEPAGE PITS I ] Depthd SizeF Number ,. _- SUMPS ❑ Distance,to nearest: Well Foundation Property Line ' DISPOSAL PONDS ❑ I I hereby certify that I have prepared this application and that the w6rk=will-be done in accordance with San Joaquin county ordinances, state laws, and rules 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,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 II re uired inspections. Complete drawing on reverse side. Signec!`)r' Title: Date: !3 YdC FOR DEPARTMENT USE ONLY p w' Application Accepted by Date Pit or Grout Inspection by. Date. Final.1pspection.by._ _ ---Dafe Additional Comments: ❑ 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 FEE CK I INFO �1]A�MMOfUNT DUE� AMOUN/T�REMITTED `CASH RECEIVED BY DATE PERMIT NO.j t EH 14-24(REV. x 51 i'[f /®�� '(f r�V //Q�4—' ✓ ��ii�+ Sy / " EH 14-26