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APPLICATION FOR PERMIT „ SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON 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 4 4A F•rcr Waterloo lRoad_ City-S-teektoFl— Lot Size _ PM � Owner's Name MarloweProoer_ties- Address p—()_ fox 7 1.1 .. Phone 44 5 J45 7 215 1 Contractor�"*.tffFi--Exn1 ora t io Address_430 Frrdrn Rd Pi t-rsht,roLicense No.4Sa802—F'hone415 692-55 t TYPE OF WELL/PUMP: --". NEW WELL WELL REPLACEMENT ❑ DESTRUCTION G PUMP INSTALLATION ❑ SYSTEM REPAIR U OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK ._.NSA SEWER LINES DISPOSAL FLD. N/A PROP. LINE 12 FOUNDATION 5 r AGRICULTURE WELL� OTHER WIt— PITS/SUMP INTENDED USETYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS _ 2rr LJIndustrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 8 Dia. of Well Casing 0 Domestic/Private $! Gravel Pack I-I Tracy Type of Casing_J?JrC Specifications .020 ' Type cetneq�Ibento I'1 Public fl Other -I Delia Depth of Grout Seal 27 T o} Grout__._ _ I I Irrigation —.Approx. Depth I : Eastern Surface Seal Installed by__ Datum Exploration Repair Work Done f-1 Type of Pump H.P. State Work Done We 11 De truction ❑ Well Diameter __ _ Sealing Material (top 501 ua*w -Depth _ Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION f 1 REPAIR/ADDITION I DESTRUCTION I '• (Na septic system permitted it public sewer is available within 200 feet.) 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 i 1 Type/Mfg - __.— Capacity No. Compartments PKG. TREATMENT PLT. 71 Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines _-_ Total length/size FILTER BED n Distance to nearest: Well Foundation Property Line SEEPAGE PITS I'I Depth Size Number____. _ SUMPS Ll Distance to nearest: Well Foundation _ Property Line -DISPOSAL PONDS .0- I ❑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 Di§trict. 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 applicant must II foyall required inspections. Complete drawing on reverse side. / JJ t Signed -.. Title: �� / l1 Cate:FOR DEPARTMENT USE ONLY Application Accepted by _ Date Area Pit or roll Inspection by J �% Cate 67 Final Inspection by Date Additional Comments: _ Cl Stk 4666781 M Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-63115 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED tiK H RECEIVED BY DATE PERMIT NO. INFO t.EN1324IREV.rrxal \�, EH 14-M