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� f 'i APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES (YEAR FROM DATE ISSUED ii. (Complete in Triplicate) Application is.heieby made to the San Joaquin Local Health Distf4for 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 welllpump and the Rules and Regulations of the San Joaquin Local Health District. N `.Job Address70 AY City Lot Size1�R�� PM f"O - 1 iQ [I Owner's Name Ci Address Phone " Contractoatl "A4_"r� Address 1��, ��'� t Gtl License No. Z Phone, Il TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ ' :1 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ f OTHER ❑ id DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE i} FOUNDATION AGRICULTURE WELL OTHER WELL ~ PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing !' C1 Domestic/Private Cl Gravel Pack ❑ Tracy Type of Casing -Al' Specifications ❑ Public Cl Other ❑ Delta Depth of Grout Seal Type of Grout____L_ 11 Irrigation --Approx. Depth I I Eastern "Ef Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. / State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') I kA Depth Filler Material (Below 501 ; TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIRIADDITION i.) DESTRUCTION l 1 (No septic system permitted if public sewer is available within 200 feet.) 111 II Installation will serve: Residence— Commercial —Other. C-,JL -Q i � s Number of living units: Number fedroo s� _ t s Character of soil to a depth of 3 feetWater table depth ! SEPTIC TANK ITy`pe/Mfg -t/%Q`7C. Capacity F a No. Compartments i� PKG. TREATMENTP t�� ' "� � Method of Disposal " Distance to nearest: Well Foundation V Property Line 5 LEACHING LINE fy-"No. & Length of lines 1 tr jTotal length'..size FILTER BED ❑ Distance to.nE9rest:-. _W811- k p h—•Foundation I gl "' Property Line —7— 'V.-* . !i SEEPAGE PITSs' I�]'06pth/ Size Number -; ' t „ r - r SUMPS ., ❑,,,,Oistance-to`,neatest: Well Foundation 110. M . --Property-Line I DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the wcrkrwill`be done in accordance with San Joaquin county ordinances, state laws, ariS;� rules and regulations of the San Joaquin Local Health District. Home owner or licensed agent's signature certifies the following; "I:certrfy`tliat in,the.performance of the work for which this permit is issued, I shall not r II employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's(tiring or sub-contracting signature q 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 m call for re fired inspections. Complete drawing on reverse side. // �}�j l/p Signed X Title: V_ Date: Ila �1 ,i0 FOR DEPARTMENT USE ONLY 7 Application Accepted by Date Area �- d"t or Grout Inspection by Date ,�., Final Inspection by &Iiz Date 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.O. Box 2009,-Stk., CA 95201 FEEINFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. + EH 13-241AEV.i/Hsl EH 14.26