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14w, APPLICATION FOR PERMIT `OF SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 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 weHlpump and the Rules and Regulations of the San Joaquin Local Health District. Job Address /q'T ` � 4Y t UtCk-e VdJU City i' Lot Size�S reZ_C,L_ Q_1 PM Owner's Nam g t �'►I vt C RL3 Address 14 -2) E'. L"L 0,-.!1�, Phone Contra' 1,-6 F. Address �Ox �� ' ee, License No:� b�a� Phone _�' TYPE O ELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION 11 SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS a� INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS N ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic IPrivate ❑ Gravel Pack ❑ Tracy Type of Casing. Specifications I•] Public 1-1 Other fl Delta Depth of Grout Seal _ Type of Grout 1 1 Irrigation —Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done L3 Type of Pump H.P. State Work Done Well Destruction L3 Well Diameter Sealing Material (top 50') DepthMaterial (Below 50'I TYPE OF SEPTIC WORK: NEW INSTALLATION I I EPAIR/ DDITtON DESTRUCTION I I INo septic system permitted it public sewer is available within 200 feet.) Installation will serve: Residence Commercial _ Other Number of living its:un3 f � Number of rooms Character of soit to a depth of 3 feet: y Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal �— Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. a Length of lines Total length/size 0Z FILTER BED ❑ Distance to nearest: Well Foundation Property Line t I SEEPAGE PITSDepth _ Size Number z SUMPS Ll Distance to nearest: Well GCS' Foundation /10 Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquip county ordinances, 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 taws of California." The applican ust call f all quired inspections. Complete drawing on reverse std q Signed X 1��- Title: __ k/r �" Date: \ FOR DEPARTMENT USE ONLY f ` 7 Application Accepted by L Date. / ,Z f1/ Area ,!� 7 of Grout Inspection by .� Date �r Final Inspection by Date 5% �A 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. Hezefton Ave., P.O. Box 2009, Stk., CA 95201 �(7 IFEE NFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. • EH 14.2E(REV.I/N s) 7f�i li ti "I , e(J -f/�iJ