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r APPLICATION FOR PERMIT tiu SAN JOAQUIN LOCAL HEALTH DISTRICT DEC 4 9939 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 E— 1VlF1':\-W1=idTAL HEALTH PERMIT EXPIRES 1 YEAR FROM DATE ISSUED PLIRVAUSERVICES (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. n1 Q�SY �atY /[/O K4/M w/L J/eL�'t-- City 4'W"6� Lot Size PM Job Address � 1 Owner's Name 1-o,.,,-o/ Address .'Ofo.azk /J" S/.A/4', n, Phone �Ia y6I: ,Z/ Contractor tS ZAW Address r. A d License No.C6";'SS"Fl,"Phone TYPE OF WELL/PUMP: NEW WELL K WELL REPLACEMENT ❑ DESTRUCTION LJ PUMP INSTALLATION ❑ SYSTEM REPAIR L1 OTHER ❑m�+r�"`01M! "'0 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE — FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS — INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Ell Industrial E) Open Bottom El Manteca Dia. of Well Excava b f O�T Dia. of Well Casing Type of Casing— �,.-- Specifications ❑ Domestic/Private X Gravel Pack ❑ Tracy YP 9 I'I Public ❑ Other 94 Delta Depth of Grout Seal �s� Type of Grout .BW sIGC I I Inigation _ Approx. Depth I 1 Eastern Surface Seal Installed by Gni �ew� Repair Work Done ❑ Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I available tic systithinem rented it public sewer is U Installation will serve: Residence_ Commercial_ Other d Number of living units: — Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments r PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size t FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I 1 Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line I DISPOSAL PONDS ❑ 1 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, 1 shall employ persons subject to workman's compensa- tion laws of California." The applicant must call for all reired i spections. Complete drawing on reverse side. Signed 1~�c,JdL� /f Title � Y--/..Z Date: -s1C--'Q : OR TMENT USE ONLY 2 2 Application Accepted by Date Pit or Grout Inspection by Date Final Inspection by Dated/-jG Additional Comments: ❑ Stk 466-6761 ❑ Lod -3621 ❑ Manteca 823-7104 ❑ Tracy 635-6385 Applicant - Return all c nvironme al Health Pe It/ "ices 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED K H RECEIVED RY DATE PERMIT NO. NFO . EH:3 24 IREV.v x 51 , per )1�1 � \� 1 O O'�O EH t4-M