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APPLICATION-FOR PERMIT rt SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 't r PERMIT EXPIRES 1 YEAR FROM DATE.ISSUED .r. �y -• (Complete inTriplicate) C 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. 1852 for wellipump and the Rules and Regulations of the San Joaquin Local Health District. tv- Job Address Ci Lot Size__ . N1 Owner's Name A � Address ��. �� KifJtl hone _f l � y Contract Address jskoea _r License No��.�. TYPE OF WELL/PUMP: NEW WELL 71 WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION L SYSTEM REPAIR ❑ OTHER L DISTANCE TO NEAREST_:_ SEPTIC TANK - SEWER LINES - DISPOSAL FLO._ PROP.zLINE FOUNDATION __. AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS } - U Industrial J Open Bottom F1 Manteca Dia. of Well Excavation_- -_ Dia- of Well Casing Vr �J C Domestic/Private ❑ Gravel Pack L: Tracy Type of Casing _ Specifications i } ❑ Public O Other O Delta Depth of Grout Seal _. Type of Grout Q ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done I- Type of Pump H.P. _ _ State Work Donedr _ w Well Destruction U Well Diameter ' Sealing Material (top 50') I Depth Filler Material (Bel ) TYPE OF SEPTIC WORK: NEW INSTALLATION f,-,e4-_TFEPAIR/pbDITION 1E DESTRUCTION ❑ (No septic system permitted if public'.sewer is �. a ilable within 200 feet.) Y._ Installation will serve: Res-idence_ Commercial._ Other �t Number of living units _6_)_ Number of bedrooms 'i Water table depth Character of soil to a depth.of 3 feet: -- - SEPTIC TANK U Type/Mfg I r Capacity — No. Compartments I PKC,. TREATMENT PLT. El Method of Disposal 1 'f t t i Distance to nearest: Well 1 I Foundation— Property Line P is I 7 n u 0 Total len h/size -- ----_ LEACHING LINE No: & Length of lines _ length/size FILTER BED 17 ,.Distance to nearest: 1711811 , Foundation Property Line \ r SEEPAGE PITS Depth 2Number f SUMPS U Distance-to nearest: Well - Foundation-= ---Property 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 laws, and rules and regulations of the San Joaquin Local Health District. t +*c*S I Horne owner or licensed agent's signature certifies the following: "I certfiy 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 componsation laws of California.-Contractor's hiring or sub-contracting signature certifies the folkrvuing: "I certify that in the performance of the work for which this permit is'issued,I shall employ persons subject to workman's compansa- tion laws of California-" The applicant mu call for all requir d inspections- Complete drawing on reverse side. { : J �2_: Title: % y��''" — Dat Signed )L / FOR DEPARTMENT USE ONLY Application Accepted by Data_ Are? - - - ... 7 Pit or Grout Inspection by Dale ._- Final Inspection by Date Additional Comments: O Stk 466-8781 O-Lodi-369-3621y EC Manteca-823-7104'""-"U Tracy'835M85 {� Appficant- Return all copies'to. Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 E AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO.' INFO tEH13-24 REV.�lw�; EH 1126