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. I APPLICATION,FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED E (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 a~ T UY Ci Lot Sizej�kv I PM Owner's Name I� Sq Phan �3" Contractor Address License No. Phon i TYPE OF WELL/PUMP: w NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTIO i� BUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ � DISTANCE TO NEAREST: SEPTIC TANK_ SEWER LINES DISPOSAL FLD. PROP. LINE t —b -' = FOUNDATION AGRICULTURE WELL--- OTHER WELL =% ='':PITS/SUMPS' INTENDED SE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 41 ' ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack;. ❑ Tracy Type of Casing Specifications ❑ Public I ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation —Approx. De th ❑ Eastern Surface Seal Installed by r pG f i 1Repair Work Done 1:1 Type of Pump: H.P. State Work Done Well Destruction Destruction ❑ Well Diameter P Sealing Material Itop 50'I - F I� Depth Filler Material IBelow 50'1 TYPE OF SEPTIC WORK: 'NEW INSTALLATION O REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is l .y 7. "�, available within 200 feet.) I h "Installation will serve: Residence_l. Commercial Other Number of living units: Nurrlber'of bedrooms r I Character of soil to a depth of 3 feet: °• Water table depth I SEPTIC TANK IN ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ { Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE -.171 Length of lines°. Total length/size FILTER BED ; p ❑ Distance to nearest: T Well Foundation Property Line SEEPAGE PITS " ❑ Depth Size Number i SUMPS ; ❑ Distance to nearest: Well Foundation - Property Line!_ DISPOSAL-PONDS. . ❑.� - - -, '!` I hereby certify 1 hat 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. Home owner or' 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 Califotnia." E The applicant mi�us�tf'call Afor all required inspections. Complete drawing on reverse side. _ Signed X (h ��//' w _ Title: —0:fwA � w ' . Date: d FOR DEPARTMENT USE ONLY Application Accepted by Date Area Pit or Grout Ir1 1l.ction by Data Final Inspection by �,te f I . Additional Co!`ments: r Stk 466-6781 ❑ Lodi 369-3621 6_lvlante6a 823-7104 ❑ Tracy _83&6385 u Applicant- Return'aIl copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201. - �iIFEE AMOUNT DUE'- AMOUNT REMITTED CA_SH CCURECEIVED BY DATE PERMIT'N0. 1+ EH 1324{REV.t/N 5Y ry�� 10 * v .tr:1- -7 EH 14-28 II r