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a APPLICATION FOR PERMIT p � SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA N -Telephone (209) 466-6761 r PERMIT EXPIRES'1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to tM 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 US for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. v T J te* Job Address 7 I'�F f�EF'` 's!E' v.l. City, T'l< Lot Size PM - Owner's Name �yAddresa Contractor �} Atldress W IJ+- rcense No.2 S5+3 ci�5 Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION El SYSTEM REPAIR ❑ OTHER ElQ DISTANCE TO NEAREST: SEPI¢JC TANK SEWER LINES DISPOSAL FLD. PROP. LINE fv FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE --7YI�E-OF WEI-i —PROBLEMA_REA CONSTRUCTION SPECIFICATIONS "\ r ❑ MSnt�ce t Dia.of Well Excavation Dia. of Well Casing ❑ Industrial "n OperS Botia ❑ Domestic/Private ❑ Grtvel Pack ' ❑ Tracy /l Type of Casing Specifications ❑ Public 0,04, kJ ❑ Delta 1 I Depth of Grout Seal Type of Grout ❑ Irrigation JtPprox. Depth ❑ Eastern Surciil Seal Installed by Repair Work Done ❑ Type of Pump .P: &+ State Work Done Well Destruction ❑ Well Diameter Sealing Material (top+60'1 Depthtt `� Fillei,Material (Below;h ) TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION ❑ (No septic system permitted if public sewer is .� t I _ available within 200 feet.) Installation will serve: Residence_ Commercial-X O�tther Number of living units: ggI' Number of bedrooms�'i— •^' Character of soil to a depth ofj 3 feet: � 1 I r c� Water table depth SEPTIC TANK )( Type/Mfg V-,4 P.rAel YY'--++ capacity /k C No. Compartments PKG. TREATMENT PLT. LII' - 1ti Method of Disposal Di}tance to nearest: Well � Foundation+,/40 Property Line � .y z j ff Total len /size LEACHING LINE 9--N &Length of lines � �4 �,-•^• 0th FILTER BED ❑ Distance to nearest: Well /I r Fodation Property Line SEEPAGE PffS' 08 tit-•—� �--'fSiza�- Number Z-` SUMPS ❑ Aatance to nearest: Well Foundation -Z C> r Property Line DISPOSAL PONDS ❑ A I hereby certify that I have prep+ed this_application and that the work will be done in accordance with Sen Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. Home owner or licensed agem's�gnature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall rot 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 compenw- tion laws of California." II The applicant must call for all squired inspactio Complete drawing on reverse side. Signed X -%�/X 7O Title: - Date: • FOR DEPARTMENT USE ONLY Application Accepted by 111 Date- �� Area Pit or Grout Inspection by Date 6,, O Final Inspection Data '�� Additional Comments: �� G r' �4.t •' �- ❑ Stk 466-6781 ❑ Lodi 9p9p 388.3621 ❑ Manteca 823.7104 ❑Tracy 835M f 7} Applicant- Return all copies to: Environmental Health Pem1h/Services 1601 E. Hazehon Ave., P.O. Box 2008, Stk., CA 95201 FEE .AMOUNT DUE AMOUNT REMITTED- CASH RECEIVED BY DATE PERMITNO. INFO a ER 1341 ill 1/951 ' EN 1L3e ��111