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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL i QN AVE,, STOCKTON, CA Tele'phohe (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) f.:':' =. Iu 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 in Joaquunty Ordinance No,549 for sewage or No. 1862 for well/pump and the Rules and-Regulati n.s of'the San Joaquin Local Health District. ff � ,, _ Job Address ' LI ' .C�(Ld L �� 1-tit Size - ' c I . PM Owner's Name 7 Address 6-1hone 1A1_7J Contractor <. u L' Address c7Sow itense No,_oNr? 3 Phone _`0 6 TYPE OF WELL/PUMP: V NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION -❑ SYSTEM REPAIR p OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK DOME, SEWER LiNES DISPOSAL FID. 120110. PROP. LINE 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 ig DontesticlPrivate t9 Gravel Pack 06 Tracy Type of Casing Specifications i'1 Public f_I Other 1-1 Delta Depth of Grout Seal _ T I I Irri4atipn --Approxi Depth i I Eastern Surface Seal installed by_ Y��.�r out Repai►,,Work Done ❑ Type of Pump H-P. State Work Done p Well Destruction ❑ Well Diameter Sealing Material {top 50'I bb Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION i i REPAIR/ADDITION I I DESTRUCTION f I (No septic system permitted if public sewer is available within 200 feet.) n Installation will serve: Residence_ Commercial Other `}1 Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth i SEPTIC TANK CI •Type/Mfg __L� PKG. TREATMENT PLT. ❑ Capacity No. Compartments 1 C Distance to nearest: 'Well of Disposal Well Foundation Property Line _ LEACHING LINE ❑ No. S Length of lines Total length/size I FILT1 R BED ❑- Distance to nearest: Well Foundation Property Line SEEPAGE PiTS I 1 Depth Size Number I SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑- i I hereby certify that I have prepared this application and that the work-will be done in accordance with San Joaquin county ordinances, state law rules and regulations of the San'Joaquin Local Health Di$trict. s, and Home owner or licensed agent's signature certifies the following: "I certify that in the perlorrimance of the work for which this permit is issued, I shall not employ any person in such manner as to become subject io 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 laws of California." The applin ust call for all requir nspections. Com Iota drawing on rs side, Signed,X 0A. _ Title' . `— _�-.r -_i. c L _ aA10: RD AR ENT USE ONLY' Application Accepted by i- Date Area i Pit or Grout Inspection by Dal e Final lnspection'by Date Additional Comments: © Stk j 466^6781 ❑ Lodi 369-3621 Cl 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 t F —, FEE. AMOUNT DUE AMOUNT REMITTED _ .)NFO H RECEIVED BY DATE PERMIT Nl?. ♦.EH14-21IREY.I/N5� .�0� �o ly� _ Q a I� EH 14-28 ' "1 I S l l� i ,