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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED ' (Complete in Triplicatel 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 weli1pump and the Rules and Regulations of the San Joaquin Local Health District. 1 Job Address w LST City L-00(1 . Lot Size t PM 1 Owner's Name l a V, TLt O'1" LIA � LA l_ Address 4.1 ! jf oke�'u�•• WI', CA Phone 361` 3501 S NJ<Na, Contractor 5 p-CI61A EulavAhovllAddress ?� L � M r� License No.cElf5121"1$ Phone KEq `1Y8"0&zi TYPE OF WELL/PUMP: NEW WELL X I (r1W-3). WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE IFOUNDATION AGRICULTURE WELL - OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ri © Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of well Casing ❑ Domestic/Private Gravel Pack ❑ Tracy Type of Casing PVL Specifications rl Public n Other Cl Delta Depth of Grout Seal 'etc Type of Grout S A b—4b- wi I Irrigation cG _ � 7�Approx. Depth I 1 Eastern Surface 5en1 Installed by Repair Work Done ❑ Type of Pump NA H.P. State Work Done ' Well Destruction ❑ Well Diameter 2." Sealing Material (top 501 0 Nbwkliv rl Wt I I Depth SS' Filler Material (Below 501 TYPE OF SEP WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I 1 DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.I Installation will serve: Residence Commercial— Otheris Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth ' SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments`' PKG. TREATMENT PLT.❑ r " ' H E i T Method Q{'�74sposa� "� � - � Distance to nearest: Well Foundation Property Line ' LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to pearest: Well Foundation Property Line SEEPAGE PITS i I Depth Size Number SUMPS L1 Distance to neatm: Well Foundation Property Lim DISPOSAL PONDS ❑ ' 1 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 D3trict. 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 Califorraa."Contractors hiring or sub-contracting signature certifies the wing: 'I certify that in the performance of the work for which this permit is issued,I shall employ persons subiect to workman's compensa- tion of Calif mia." The applica ust call f all r fired inspections. Complete drawing on reverse side. Signed Title: e)^c-10 �G 41 S, � Date: 0 4 3 ' FOR DEPARTMENT USE ONLY 7 J l•Oi� Application Accepted by __. Date Area 433! Pit or Grout Inspection by Data Final Inspection by Date Additional Comments: OnI 01 O r l ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7ml ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk•, CA 95201 FEE +. AMOUNT DUE � A�MOU�NT RFMI TED +C, � � RECEIVED BY DAlTE4!� PER.MIT'NO .EMFO ASH EH }2lIREV.1��61 12 Mrr{ eH 14M 003