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.x M Ly APPLICATION FOR PERMIT , oG' ` SAN JOAQUIN LOCAL HEALTH DISTRICTZ�d' " � l 1601',E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 4 PERMIT EXPIRES 1 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 a3 10 1 City Lot Size3-AQA 6'90 PM Owner's Name v' a jn4 -� f h Address 12-50 ��R �.PT�, Phone w _ 7 L, } Contractor's Norrie icense No. Phone TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK !IM i" SEWER LINES 1i q+ DISPOSAL FL D.&2Z4 PROP. LINE t � j FOUNDATION 3Q� AGRICULTURE WELL � OTHER WELL PITS/SUMPS]"C3-0 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICA ONS 0U ElIndustrial Xbpen Bottom ❑ Manteca Dia. of Well Excavation IL Dia. of Well Casing 0 � omestic/Private El Gravel Pack , ❑ Tracy Type of Casing - Specifications [a ❑ Public- ——0 Other --❑'Delta'"'"""' """"`""DepTh of Grout Seal Type of Grout ❑ irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by r Repair Work Done ❑ Type of Pump __ H.P.�: % :/-' State Work Done tion- ❑ Well Diameter Sealing Material (top 501 d Ar Depth Filler Material (Below 501 T PTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ Wo septic system permitted if pbblic sewer is available within 200 feet.) Installa#ion will serve: Residence_ Commercial_ Other u -r r Number of living units: Number of,bedroams , Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments - .� ¢ PKC. TREATMENT PLT. ❑ Method of Disposal l i Distance to nearest: Well Foundation Property Line r .a+ LEACHING LINE ❑ No. 9 Length!of lines Total length/size FILTER BED ❑ Distance to nearest: Well"""' _ ""'Foundation Property Line i � t SEEPAGE PITS ❑ Depth Size Number - SUMPS i "❑ Distance to nearest, Well Foundation_ Property Line DISPOSAL PONDS ❑ .. �, I �' ., I hereby certify that I have prepared this application and thai N e work will be done in accordance with San Joaquin county ordinances, state laws,and rules and regulations of the San Joaquin Local Health District. `t Home owner or licensed agent's signature certifies the'following:%'01 c rtify that in the performance of the work for which this permit issued, I shall not employ any person in such manner as to become subject to wa'rkman�s cbmpensation laws of California."Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of te'Work foi which this permit is issued, I shall employ persons subject to wo`rkman's compensa- tion laws of California." The applicant m t II f all requir inspecti mplete drawing on reverse side. Signed X Title: r f� - Date: R-DEPARTMENT USE ONLY 1i1 Application Accepted � Date", Area ,��J �- Pit or Grout-Inspection by y ate , Fi� Inspection by Date 6L�� _r V 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!8ox 2009, Stk., CA 95201FEE + INFO AMOUNT DUE AMOUNT REMITTED CASH CK 0 RECEIVED BY DATE PERMIT"NO. + EH 13-24 1REV.10!831 � 145" —��