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V APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA } 37 2q5' Telephone (209) 466-6781 —'L9 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 ? 99 0 ItP 11 p City--f �Lot �Size 3 &d-" _ PM Owner's Name Address {�� S '�"q��Or1— — hone S 5W o�f r ml-/e 2lw� vS4`t Contractor Address 13%ftme ®tl�cLicense No.;y%sy.Z Phone 'f-1 TYPE OF WELL/PUMP: NEW WEL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION� SYSTEM REPAIR ❑ OTHER ❑ �� DISTANCE TO NEAREST: SEPTIC TANK _��— SEWER LINES I DISPOSAL FLD._1_0Q_%PROP. LINE AT FOUNDATION AGRICULTURE WELL T OTHER WELL PITS/SUMPS JSP a INTENDEDUSE Wyk PE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 8,r ❑ Industrial \\D pen Bottom ❑ Manteca Dia. of Well Excavation�� Dia. of Well Casing onnestic/Private C,--(!!Gravel Pack ❑ Tracy Type of Casing Specifications /❑ Public „��. f ❑ Other ❑ Delta Depth of Grout Seal '� Type of Grout 9� I I Irrigation 12=5VApprox. Depth I I Eastern Sud ce Seal Installed by Repair Work Done ❑ Type of Pump Su h H.P. - State Work Done Well Destruction % Well Diameter Sealing Material (top 50') Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Tf� Installation will serve: Residence_ Commercial_ Other Number of living units: _ Number of bedrooms Character of soil to a depth of 3 feet: - Water table depth SEPTIC TANK ❑ Type/Mfg pacity No. Compartments ` J PKG. TREATMENT PLT.❑ Method of Disposal Distance to nearest: Well Foundation Property Line S' LEACHING LINE Cl No. S Length of lines Total length/size— FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS Ll Distance to earest: Well Foundation Property Line 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, an rules and regulations of the San Joaquin Local Health District. Home owner or licensed agent's signature certifies the following: "1 certify that in the performance of the work for which this permit is issued. I shall no 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, I shall employ persons subject to workman's compensa- tion laws of California." ! o The applicant t 1 for all required i actio omplete drawing on reverse a. ® Signed / Title: Date: FOR DEPARTMENT USE ONLY oCco Application Accepted by Date79" Area �1�,,�Area 6 0y,) Pi[or Grout Inspection by Date : F,iinnaall Inspection by /z /t= � Date O V Additional Comments: -y �'- �7� L' 2P'4' �` _ fr`"fes - v` !/ �9�J ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 827100 ❑ Tracy 835-698 v a-.2;L (7 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMO NT REMITTED CASH RE EIVED BY DATE PERMIT NO. INFO EH 1IREy.v x EH l4-MI-]a