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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. .HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 'I.YEAR FROM .DATE ISSUE® ,. ,.W� r ,.,,.. �r, . (Complete in Triplicate) . y . , ,. ( r�r� �,.�.. r. ► 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.J862forweil/pump and the Rules and Regulations of the San Joaquin Local Health District. �y_.1. .P` Job Address .I 9 /!?dAl� ii('/W.r eV city 1 Lot size �?l �,_� PM - ; W Owner's Name� 'dr�i�/ AJ Address 4- Phone Contractor's Name licensea:N 'r` �' Phone Q TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION D SYSTEM REPAIR ❑ OTHER F-1 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS �y � 5 T INTENDED USE TYPE OF WELL.y PROBLEM AREA„,F;CONSTRUCTIdN_SPECIFICATIOiVS _ F. Y ❑ Industrial C3Opeli Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private' ❑ Gravel•Pack ❑Tracy,,X, Type'of Casing Specifications ..,w.._ .Z -,v� i.5z"- - '- ❑ Public ❑ Other .i. ❑ Delta Depth'of Grout Seai '� T Type of Grout ❑ Irrigation a __4pprox�Depth ❑.Eastern '. Surface Seal installed by ^ Repair Work Done ❑ Type-of'_Pumpt -yH.P ` ^-4^ �' ^^ —State-Work-Done^ f' Well Destruction ❑ Well Diameter �,. Sealing-Material (top 50'1 t. _r ,Depth L—Filler_Material .(Below-50.) TYPE OF SEPTIC WORK: NEW INSTALLATION _ ?REPAIR/ADDiTION ❑ DESTRUCTION ❑ (No septic system permittedapuwer. available within 200 feet.) Installation will serve: _Residence>�/ Commercial'_ Other Number of living Units —/—/- �jNumber ofooms Character of soil to a-depth off 3 feet: Water table dept SEPTIC TANK © Type/Mfg on4&eJy "' ' ` Capacity.lbf� No. Compartments PK'G'.°TREATMENT•PLTi'Q`: Method of Disposal ! ` y f- �,,;',^, ,�;� �,•rX'� � �� Distance to nearest: �Well�'�- Foundation �*� Property Line ` A1'1 4 " T6tal'len th/size a LEACHING LINE No. & Length of lines g ,�, �: FILTER BED i ❑- Distance to nearest: #Well: �"-"'Foundation�=0 r Property Line . �! SEEPAGE PITS ❑ Depth Size Number SUMPS 4 ❑ Distance to nearest: Well Foundation Property--tine k DISPOSAL PONDS ❑ • 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 I rules and regulations of the San Joaquin Local'Health District. 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 or sub-contracting signature s hiri certifies the following: "I cerfify that in the performance of the work for which this permit is issued,I she[]employ persons subject to workman's compensa- tion laws of California." F The applica t call for all Aurred inspections. Complete drawing on rever s Title: Date: Signed -. . . s I F DEPARTMET E qN& �y __ T .- �� - »- •1__ r D Area Application Accepted by Datar Pit or Grout Inspection by } ate r - Final Inspection by. Date Additional Comments: all ❑ Stk -466.6781 ❑ Lodi-369 1' Q Manteca 823-71 ❑:Tracy 835-6385 i �Applicsnt- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 z ..j Cr r £ *FEE "?AMOUNT DUE it AMOUNT REMITTED Y CASH RECEIVED BY DATE PERMIT"N0. g INFO + EH 1324(REV.101831 € ; I ( f V EH 1426 `