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r Y APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL i ON AVE., STOCKTON, CAI 1 Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUEDIur�i 2 ' (Complete in Triplicate) I Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or inSt�l�� ,� , This application is r made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump andons of the San Joaquin I Local Health District. ! R Job Address 7�� I C 1!: 1 - qCi City —AW-7 Lot Size PM Owner's Name J e vf� Address o fJvs+��W r ra`7$ Oe . Phone fs OG— `Y1 Contractor Vd dgAddress 3233 Ft 1{Z 2K License NoC5� Phon�WI '727 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION PUMP INSTALLATION ❑ SYSTEM {PEPAIR ❑ OTHER ❑ 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 `In Dia. of Well Casing ❑ Domestic/Private R Gravel Pace Tracy Type of Casing ¢vc specifications j_ i`l Public f_1 Other F1 Delta Depth of Grout Seal Type of Grout its I I Irrigation ZZ-Approx. Depth ( I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction X Well Diameter Sealing Material [top 50'1 Depth t Filler Material (Below 501 _ TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION (No septic system permitted it public sewer is r available within 200 feet.) AAInstallation will serve: Residence—j Commercial— Other 1" Number of living units: Number of bedrooms Jf 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 13 Distance to"nearest: Well Foundation Property Line A SEEPAGE PITS I ) Depth t SizeNumber uMPS L Distance to{nearest: Well Foundation Property Line DISPOSAL PONDS ❑ - 9 k 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. „ Home owner or licensed agent's signature�cenifies 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 on reverse side. Signed X Title: vee 6 Q Date: I FOR DEPARTMENT USE ONLY Application Accepted by Data YJ Area I�°t Pit or Grout Inspection b �L> &,7elz Y Datnspection byDate Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-36211 ❑ Manteca 823-7164 ❑ Tracy 835-6385 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 RECEIVED BY DATE PERMlT NO. tNFO SH +,EH1 -241REV.ifksl '�/, GTOv w7 '^7 3-� EH 14-26 11 6 i