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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT E 1601 E. HAZE.I ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES t 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. 1962 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. if r Job Address ,e Job / ��G kod city p Lot Size PM Owner's Name / aP4� )4!&/6u atjL Address O`1Die- Phone�`�/ 9 Contractor ;!51,&j ,..st �dr�e �,wssL �/! r u++ License No _Phone X'.►Z ff TYPE OF.WELCIPUMP.- * —NEVA WELL^❑ WELL REPLACE NT.❑' DESTRUCTION ❑, a_ 5} 1 , 'r PUMP INSTALLATION Cl f'-�SYSTEM REPAIR.❑ ,,.� OTHER ❑ _DISTANCE TO NEAREST:_SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL A OTHER WELL PITS/SUMPS ! l . INTENDED USE TYPE OF WELL PROBLEMAREA CONSTRUCTI N SPECIFICATIONS I ❑ Indbetrial' `.� rO Open Bottom ❑ Manteca Dia. of Well EExxcavatifin s Dia. of Well Casing -' O Dome3tic/Private= _ O'Gravel Pack• ❑ Tracy `Type of CAI'I Specifications i :Ewers n other ❑ Delta Depth of Grout Seal { Type of Grout _ ( 1Prigatioq, ,+ Approx..Depth I 1 Eastern Surface Seal Installed by 1 Repair Work Done. ❑ (Type of Pumpl H.P`'s. _ State Wq�k Done_ Well Destru4ctiori` '"0?1 Well Diameter 1 Sealing N�,eterial J(op 50 1 \ \''��Pt11— t • Filler Material (Below 501 I TYPE OF SEPTIC WORKS PNE! IN'TALLATIO(I^I. vSREpA_IR/..ADDITION V DESTRUC71ON_ 1 1 (No septic system permitted it public sewer is r,s available within 200 last.) _ Installation willserve' rdence— Commercial—,Other :.___ Number of living unit _ _•--Number of bedrooms Character pf.spJ,to (depth z'7eet: •S i4 Nr� .� • '� �''K �J� _ z Water table depth SEPTIC TANK ❑ 4'ype � yl Capacity ,-_ No. Compartments {PK-G. TREATMENT PCR.❑ wi '•;f r Method of Disposal I�'- Distance to nearest: Well Foundation Property Line .00 L--- ------------------------- jNE ING N �� ❑ No. & Length of lines �— Total length/size FILTER bb ❑ Distance to nearest: Well ��J \ O L I 1 f Foundation fi \ _ Property Line ''sry. I \/�1i/N1 11 SEEPAGE PITa�srfrwr�py "Depth �_* • Size _ Number SUMPS ❑ Distance to nearest: WON Foundation Property Line _ DISPOSAL PONDS ❑ 1 - I hereby certify that 1 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 of licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, 1 shall not employ any person in such manner as\to become subject to workman's compensation laws of California." Contractors hiring w sub-contracting signature certifies the fotlowirt "I certify that in tion laws of California."'nithe performance of the work for which tits permit is issued/1(half employ persons subject to workman's conpensa- H,j`T The.applicaanntt call for re it in action/ss.. Complete drawing On revs siddi., v Signed Date: ~�7'•'�/ ^w - ��te1� FOR DEPARTMENT USE ONLY 9 Application Accepted by �, �Alt� Date "� •� CJ Area O r, Pit or Grout Inspection ' Date -I \;-`Final Insp"ectionby , i'l I ` OW �7 Additional Comminta: u t O eip�,ati. ❑ Sik 466-6781 ❑ Lodi 369 t ❑ Manteca 823-7104 ❑ Tracy 035.6385 Applicant Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton_Ave., P.O. Box 2009, Stk., CA 95201 I FEEINFO` JJ�{�'AAMOUNT DUE •AMOUNT REMITTED K �7 RECENED By DATE - PERMIT,NO. . EN Ia.N IeEV.ir.�i / (D �,/L3 �� /��I/ /yt _ 7�L fN a-N _ / 'f ( �C