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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT ri 1601 E. HAZELTON AVE., STOCKTON, CA x. Telephone (209) 466-6781 PERMIT EXPIRES 'I 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 Local Health District. Job Address ............ City Lot Size 6 �� PM Owner's Name ,� (�.d P 1l�' ��*zts'ddress Phone �� t Contractor : �'Zi /-i ,� Address e /W License,No. !? b Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ i OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD.____— PROP. LINE FOUNDATION AGRICULTURE WELL OTHER MILL— PITSISUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation '� Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications Cl Public ❑ Other Cl Delta Depth of Grout Seal Type of Grout Irrigation- _:Approx.,Depth l-I Eastern. Surface.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:r_.NEW INSTALLATION REPAIR/ADDITION I I DESTRUCTION l I (No septic system permitted if public sewer is I available within 200 feet.) - i ) Installation will serve: Raidertce jk:�' Commercial_ Other Number of living units: -_J__2"-(Number of bedrooms Character of soil to a depth of,,3;feet: 4 401/4' Y -+► Water table depth 1 SEPTIC TANK ❑ Type/Mfg RE 4,0 Capacity No.'Compartments I PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation /,I Property Line_,""72 # LEACHING LINE No.& Length'of lines " Total length/size ;. st: Well lJrdfoun ation ` Property Lin FILTER BED ❑ Distance to neare SEEPAGE PITS l I` Depth r Size Je Number- SUMPS umberSUMPS}' Distance to nearest: Well IS02 'r'F Foundation� UFT Prop yrT Line 5U 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. J.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 c suit- ontracting 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 rdorkmans compensa- tion laws of California." w + The applicant mustcall f3ball re wired inspections. Complete drawing on reverse side. Signed X Title: ._. Date: DEPARTMENT USE ONLY Application Accepted by0Date +2 Area n pit'or-Grout Inspection by Date Final Inspection by ate �a �J Additional Comments: ❑ Stk 466-6781'; ❑ Lodi 369-3621 ❑ Manteca 623-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 3 ; f a d F w f INFrS AMOUNT DUE AMOUNT REMITTED+ `CASH b` RECEIVED BY +^� `DATE PERMITNO. + EH 13-24 IREV.I/ E-N a-_26