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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT F1601 E. HAZEL T ON AVE., STOCKTON, CA - Telephone (209) 466-6781 PERMIT EXPIRES 1'YEAR FROM DATE ISSUED l (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. oz istr . oz L` {� Job Address T 7 City � f Lot Size 4 PM Owner's Name LfA zn Mo Address _V,4'At a Phone-le.F- #4 Contractor Ftp AD t5, gi p-__Address 7 Al, 4De413027_ License No. L7_S: -7L Phone a=3 `}71 �f. TYPE OF WELL/PUMP: NEW WELL O WELL REPLACEMENT r-1- - DESTRUCTION ❑- 1 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ 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 CON57RUCTION SPECIFICATIONS ❑ Industrial -❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications " ❑ Public ❑ Other 171 Delta Depth of Grout Seal Type of Grout I I Irrigation —Approx. Depth l 1 Eastern Surface •1 Installed Pp P Sea ! sta led b y _ \ Repair Work Done C] Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50'1 \� Depth Filler Material (Below 50'1 T� F TYPE OF SEPTIC WORK: NEW INSTALLATION 1.-1 REPAIR/ADDITION DESTRUCTION I 1 (No septic system permitted if public sewer is available within 200 feet.I .I Installation will serve: Residence�' Commercial_ Other - -----Number-of-living-unitsr=_-_L_—-Number-of-bedrooms_-__? __.._--- --- --..,--._--.---.--,_----.__----__.—.____ __- ---------.---- Character of soil to a depth 0 3 feet: Water table depth SEPTIC TANK Q' T e/M# �t ,_`__ n Z � YP 9 --t�C:� `'1'��- Capacity f Z�IJ No. Compartments , PKG. TREATMENT PLT.© Method of Disposal OF Distance to nearest: Well _� Foundation /� r Property Line 7 I r zX' LEACHING LINE No. & Length of lines Total length/size` i x y FILTER BED ❑ Distance to nearest: Well IZ=d Foundation 3t? ° Property Line 7�z i E fh SEEPAGE PITS 141-*"-Depth .-Size ' 3 �r Number SUMPS ❑ Distance to nearest: Well Foundation -"S 22i z_ Property Line DISPOSAL PONDS ❑ ' fi 'r 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 whicA this permit is issued. I shall not employ any person in such manner as to become subject to workman's compensation taws 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 applicant must call for all required inspections Complete drawing on reverse side. ' Signed*X Title: &ml Date: Fl. FOR DEPARTMENT USE ONLY A plication Accepted by Date Area J 1 51 1 Pi �or G'rout Inspection by Date Final Inspection by � � 'Dat �. i Additional Comments: ❑ Stk 466-6761 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835--6385 f Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201FEE Il INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVECKO D$Y DATE PERMIT NO. H E . r51- IrEH 44-26 6 �'C((//� Q �