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APPLICATION FOR PERMIT ~ j SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON'AVE.,"STOCKTON, CA Telephone (209)466-6781 PERMIT EXPIRES 1'YEARIFROM-DATE ISSUED (Complete in Triplicate)' e 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 -7 6' b fUn'Sc✓r_G + "- City ceif�t4- Lot Size ''t" __ PM / r 10 f "tli:.,u7 4 slR;C ::I t`O :�l3Jiv.: [wi 8r - • :c�� •-owrier's Name .� Prl� R• - 5mAcdress _ �Nt�/ _ --- - Phone _ I Contractor A�._ �-u�(r�r' Address _ L'�.�'~�11 License No. I d-Phone., �u�sl r TYPE OF WELL/PUMP: i NEW WELL C WELL REPLACEMENT 7 DESTRUCTION ❑ PUMP INSTALLATION 1. SYSTEM REPAIR C OTHER _I DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES --- DISPOSAL FLD.__ PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL_. PITS/SUMPS INTENDED USE TYpE_OF WELL.—PROBLEM AREA CONSTRUCTION SPECIFICATIONS E i C I Industrial ❑ Open Bottom C Manteca Dia. of Well Excavation -_ Dia. of Well Casing j I I Domestic/Private 1.. ❑ Gravel Pack C Tracy Type of Casing _ Specifications r CI Public ❑ Other C Delta Depth of Grout Seal — Type of Grout Q Irrigation � D pprox. Depth I_ Eastern J,iSurface Seal Installed by r �W '1 Repair Work Done I Type of Pump-- l_ _J_ H.P. � ' '� r`-. State Work Done Well Destruction J Well Diamete, I Sealing Material (to/p 50'1* Depth `l 'I Filler Material (Below 50'I r1��. _._ _1 TYPE OF SEPTIC WORK: NEW INSTALLATION'C j REPAIR%ADDITIONS-DESTRUCTION L (No septic system permitted if public sewer is t r available within 200 feet.) Installation will serve: Residence_ Commercial_ Other f Number of living units: I Number of bedrooms._ Character of soil to a depth of 3 feet: _. _ Water table depth SEPTIC TANK J Type!Mfg _ Capacity No. Compartments PKG. TREATMENT PLT. " ' Method of Disposal, Distance to nearest: Well Foundation Property Line LEACHING LINE No. & Length of lines I ^r� g � �!{� Tote)length/size_-._Q__. FILTER RED 51/0 istance to nearest: Well 1Q� Foundation -_� ,Prop ty Line SEEPAGE PITS D Depth Size Number.— SUMPS _ Distance to nearest: Well Foundation Propgrty Line DISPOSAL PONDS } ` '�_.� Ij f 1 a; . I herebycert that I have i rfY 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. I I `' V.-,I I i7r�)i ' •, + �{ 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 compensation5aws of California." Contractor's hiring'or sub-contracting signature I certifies the following: I certify that in the performance of the work for which this permit is issued,'I shall em-pldy,peisons subject to workman's compensa- tion laws of California." i c t r The applicant must call for all required inspections. Complete drawing on reverse side. Ire 'y` ��L I Signed X- I fu/ _ _— flilate: \(` FOR i`EPARTMENT USE,ONLY') dJ -"App►ic_asion-ACWte -by ---- ' Yif/LGt%Y'� V `Y `. Dat Pit or Grout Inspection by' AIIA- Date Rnal Inspection by Date J Additional Comments: _ s_I Stk 4666781 1 : Lodi 369-3621 _. Manteca 823-7104 _ Tracy 835-6386 Applicant - Return all copies to: Environmental Heath Permit Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'N0. . EH 13.24(REV. EH 14-26 {