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vp-r APPLICATION FOR PERMIT ,rte 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 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. /� Job Address 13'nolo s/� LTe "'f City T�'r+�;y Lot Size PM Owner's Name OWP VX GLRTf lj741'4'yr Address O S ty✓L re sa Phone Contracts AN Oev d Ser Address �2 L P9ad40s7C License No. yya 1?9! Phone ;-Y:i�l' TYPE OF WELL/PUMP: NEW WELL ❑ WELL FEPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ STEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FCD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEMAREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications I"1 Public ❑ Other F1 Delta Depth of Grout Seal Type of Grout I I Irrigation —Approx. Depth I I Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump H.P. State Work Done i Well Destruction ❑ Welt Diameter Sealing Material Itop 501 0 Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION W REPAIR/ADDITION l I DESTRUCTION I I INo septic system permitted if public sewer is Q available within 200 feet.) Installation will serve: Residence— Commercial-,V_ Other Number of living units: _ Number of bedrooms Character of soil to a depth of 3 feet: //C/�✓y Lour Water table depth 02, SEPTIC TANK I4 Type/Mfg Ply C�l9T CapacityI.ZOO No. Compartments �. PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well deo Foundation.._ Property Line Ya LEACHING LINE (?f No. & Length of lines/ Total length/size love FILTER BED ❑ Distance to nearest: Wall -Top Foundation is8Property Lim SEEPAGE PITS 11 Depth /O' Size 6'X/o'X/O Number SUMPS 11( Distance to nearest: Well Foundation Property Line DISPOSAL PONDS I I 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 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." Contractors hiring or subcontracting 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 XLL6' �E' Title: Data: /1"/s—b� DEPARTMENT USE ONLY Application Accepted by Date � Area /IT Pit or Grout Inspection by D e Final Inspection by • Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6185 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 NFEE FO AMOUNT DUE AMOUNT REMITTED I UK CA SH RECEIVED BY DATE PERMIT NO. . EH to 24(REV.11 n 5) .. �,�, oo EH t4 a