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y3 - ext APPLICATION FOR PERMIT r 1 SAN JOAQUIN LOCA HEALTH DISTRICT / 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 6, ,4 ,4 (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 SII/pump and the Rules and Regulations of the San Joaquin Local Health District. r a Job Address 4'5-6 CityA---C Lot Size —22 . .tom. Pm ' w 14 A �7/ E a-u~ Address ® Phone -�oGF� Z Owner's Name CA$3 5 1 Contractor f '�.irK Address I/'� "I License Novo--�Ph,, TYPE OF WELL/PUMP: NEW WELL09, WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR )J OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES ;� DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS 4 k._ INTENDED USE TYPE OF WELL r PROM AREA CONSTRUCTION SPECIFICATIONS S ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Specifications .Gravel Pack ❑ Tracy Type of Casing Pr ['1 Public ❑ Other ❑ Delta Depth of Grout Seal %. Type of Grout I I Irrigation Approx. Depth l I Eastern Surface Seal Installed by - Repair Work Done LJ Type of Pump H.P. State Work Done _ Well Destruction El Well Diameter Sealing Material (top 501 i — Depth Filler Material (Below 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION {-1 REPAIR/ADDITION Ll DESTRUCTION I i INo septic system permitted if public sewer is available within 200 feet.) Installation will serve:. Residence— Commercial_ Other y Number of living units: Number of bedrooms Water table depth J_ Character of soil to a depth of 3 feet: - Nry o. Co SEPTIC--TANK �= .FDIT-ype/°Mfgap. ?.: �>�...- F, �r� _ Capacity W� ;ic e-----� ." • yw+� '. -.� PKG. TREATMENT PLT. ❑ -� n Metho 1 ^ Distance to nearest: Well Foundation Property Lin�WE W � 4 LEACHING LINE ❑ No. & Length of lines Total length/size JOAQUIN COUNTY �. f FILTER BED ❑ Distance to nearest: Well Foundation Prope �A�SERV)CES t'� V SEEPAGE PITS [ I Depth Size _ Number SUMPS hl 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, sta`e laws, and rules and regulations of the San Joaquin Local Health District. y that in the performance of the work for which this permit is issued, I shall not Home owner or licensed agent's signature certifies the following: "I certif employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring of sub-contracting signature certifies the following: 'II 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 r Title: e[n Date: 1-5-1r, -5-1 FOR DEPARTMENT USE ONLY _ �^ , Date / Area Application Accepted by Pit or ro inspection by Date ainal Inspection by OQ Date��6 I , 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:0 8arr �tk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED By DATE PERMIT'NO. INFO kk ♦,EH13-24(REV.I/K5) - ��0� / # o EH 14-28 L