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APPLICATION FOR PERMIT &1-k VAWMI SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 - Q t. (9`12 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED PAA44-t- (Complete in Triplicate) ®wh1�4)00> 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 I O 1 f �1� ` C i �/ �� City tot Size �` �+ PM Owner's NameAddress Phone ,/� y ! vl4* 0 RlnGt Contractoreei TWLitb44 Addressf'r0._A7 [.1 01 S License No17)OSrr Phone33 _ y TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ ` PUMP INSTALLATION i SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE 1O FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom Cl Manteca Dia. of Well Excavation Dia. of Well Casing Domestic/Private {Gravel Pack ❑ Tracy Type of Casing AVC Specifications 1-1 Public n Other 71 Delta Depth of Grout Seal Jr IL Type of Grout CC.Iyrl' I I Irrigation --Approx. Depth i I Eastern -4�L sSurface Seal Installed by L .`7"t/1�c n t _ Repair Work Done El Type of Pump s V n H.P. J State Work one _ s Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth '� S Filler Material l8elow 50') TYPE OF SEPTIC WORK: NEW INSTALLATION 1:1 REPAIR/ADDITION LI DESTRUCTION € I (No septic system permitted if public sewer is available within 200 feet.l ' Installation will serve: Residence_ Commercial_ Other _ Nu ving units: Number of bedrooms Character of soil t7PLT. E] of 3 feet: Water table depth SEPTIC TANKType/M g Capacity No. Compartments PKG. TREATMENT ' Method of Disposal Distance to nearest: Well Foundation Property Line 7 1 LEACHING LINE ❑ No. & Length of lines oral length/size FILTER BED ❑ Distance to nearest: Well " Foundation operty Line SEEPAGE PITS I'I Depth i Size Number SUMPS 0 Distance to nearest: Well Foundation Property Line ) DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state taws, and rules and regulations of the San Joaquin Local Health District. l 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." 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 "7- lG.,_ applicant must all for all required inspections. Complete drawing on reverse side. Signed)� .�� /L�h .__. Titles �itl1►�N ._._. Date: J 7 1 t FOR ARTMENT USE ONLY Application Accepted by � .Date 7_69 9�� Ara Q Pito Grout spection by Date '(1/ Final Inspection by G Dat�Y22�� Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Slk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED 11CA�S}H RECEIVED BY DATE PERMIT'NO. + EEm 324 H t4.2g IpEV.tiks� l CIS-. �P 1 F �'! 7,/d r�7