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IN t. APPLICATIOWFOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED AUG 3 107 l (Complete in.Triplicate). ENVIROMENTAL HEALTH Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein d!1E is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations o the San Joaquin Local Health District. "" " F i f at- Job 4 Job Address I—a �.5 ¢4 -L City Lot Size PM Owner's Name Q� Address � S �OK .�� Phone ii Contractor t`tCt:� _Address PjO 11311 e, License No.�s�iPb72- Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION Ti PUMP INSTALLATION- -SYSTEM REPAIR ❑ 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 El Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing `9omestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ,f ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation --Approx.'Depth ❑ Eastern r urface Seal Installed by I� Repair Work Done ❑ Type of Pump -�.t.� _ H.P. Z� State Work Done �E Well Destruction ❑ Well Diameter Sealing Material (top 54') Depth + Filler.Material (Below 501 I` TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) I, I Installation will serve: Residence_I Commercial_ Other j Number of living units: Number of bedrooms i Character of soil to,a depth of 3 feet�. Water table depth fSEPTIC TANK :.Cl) Type/Mfg Capacity . No. Compartments PKG, TREATMENT PLT. ❑ � Method of Disposal Distance to nearest: Well Foundation Property Line f r LEACHING LINE Cl No. & Length'of-lines '—Total length/size FILTER BED 0 Distance to nearest: -Well Foundation Property'Line SEEPAGE PITS ❑ Depth fi Size Number SUMPS ❑ Distance to nearest: Wsll 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 coup Joaquin ordinances,R county aces, 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 t calf fo�all required inspections. Complete drawing on reverse side. i j Signed X •-� Title: bate: l i FOR PARTMENT USE ONLY I Application Accepted by Date �y Area�� - i Pit or Grout Inspection by � Date final Inspection by Date Additional Comments: 1 � ❑ Stk 466-6781 r ❑ Lodi 369.3621 .❑ Manteca 823-7104 ❑ Tracy 8355-6385 Applicant- Return all capios'te-Eavirorimental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 ! A INFO AMOUNT DUE -� AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. � r + EH 1 -24IREY.)/a5) '41 /1 ,)�7 EH 14 128 �(�� - —(,11 �/