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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON 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 ap ' tan is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/ and ha Rules and Regulations of the S Joaquin Local Health District. _ Job Address /t y4s` VA � RL!5 Zoj �til� City � �/ of Size M �! Owner's Name Address�,L�6tg� Y'b �F,J Phone s"r Coat s Name Lrcen o. > Phone " TYPE OF WELL/PUMP: NEW WELL,p WELL REPLACEMENT ❑ DESTRUCTION ❑. . PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑'. DISTANCE TO NEAREST: SEPTIC.TANK' SEWER LINER DISPOSAL Fl PROP:LINE+. FOUNDATION AGRICULTURE WELL OTHER WELL -PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA Y ONSTRUCTION SPECIFICATIONS r ❑ Industrial ❑ Open Bottom O Manteca /k.Dia..of WAIT Excavation Dia. dwell Casing C Domestic/Pdvete C Gravel-Pack 1 ❑Tracy 'Type of Casing Specifications ❑ Public ❑ Other ❑ galta Depth of Grout Seal Type of Grout ❑ Irrigation --4pprox. Depth ❑ Eastern Surface Seal Installed by r Repair Work Done ❑ Type of Pump H.P. ! State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 60') Depth Filler Materiel (Bela 60') TYPE OF SEPTIC WORK: NEW INSTALLATION XREPAIR/ADDITION ❑ DESTRUCTION C (No septic system permitted if public sewer is .�\ r ! 1• available within 200 feet.) Installation will serve: Residence--\--Commerclei_ Other Number of living units: I Number of bedrooms P1 �s Character of soil to a de�p,t/h of 3 feet: ^ )Nater table depth SEPTIC TANK 4� Type/Mfg Pqg came nE/ pac'ty t� s� Jo. Compartments PKG. TREATMENT PLT. ❑ — r Method��oft�D+.iw�saplolset � �+ Distance to nearest: Wall Foundation 10{ Property Une L�J� LEACHING LINE No. &Length of lines Total length/size Z, FILTER BED ❑ Distance to nearest: Well ` Foundation_199 Property Line SEEPAGE PITS,/"). . / 'yd Depth �•5 Size Number �i < IQW SUMPS C 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, 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 shell employ persons subject to workman's compensa- tion laws of California.- Th��(pPlicant mat call for,all requireQLinsperhions.Compl to tlrevfi7rn-a verse side. Sigheday t.�y. J�� I i✓✓din-0llwtu-.. Vr- frs.Y.rtll,,,a`.l't.' f �:,d4't..l� Date: ate D" i'y L FOR DEPART ENT USE ONLY A lication Accepted by Date 410 Rt r Grout Inspection by a a Q-r}S' Final Inspacdon by we iiAdd'Tonal Comments: )k?lStk 466-6781 ❑ Lodi 369-3621 C Manteca 8237104 ❑ Tracy 83.5-8386 A'�Qlicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE NFO AMOUNT DUE AMOUNT REmrFMD CA6M gECE1VED BYDATE PERMR NO. ' ;�(REV.10/831 _��Li $$ ESs X110.3