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N APPLICATION FOR PERMIT �1 -.:.,,,'-SAN JOAQUIN LOCAL HEALTH DISTRICT Imo" 1601 E. HAZEL T ON AVE., STOCKTON, CA �a� •!'.%' `r ,�''" `�•� /,;S Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ;.11,0�.��;�� 4..�`'.•,.r – — �.. S- Application in Triplicate) low 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. r �j Job Address S / '/a in S f/<-1-7L City EsG�f�� Lot Size PM Owner's Name j)�C.jb✓ f <<.' 0✓� Address =1hM Phone Contractor Meje� Sle"c+- Address ��U��CS/L� License No. � U Phone_ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 1-1 DESTRUCTION L 1 / PUMP INSTALLATION ❑ SYSTEM REPAIR Ll OTHER h S-c-,s J Lejk15 (� 1 DISTANCE TO NEAREST: SEPTIC TANK �— SEWER LINES DISPOSAL FLD. PROP. LINE J / FOUNDATION AGRICULTURE WELL. _ - OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Ll Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavatio Dia. of Well Casing LI Domestic/Private Cl Gravel Pack 1.1 Tracy Type of Casing-140ti Specifications `► r r•1 Public ba Other (-I Delta Depth of Grout Seal +�+ D�`I Type of Grout-*!� I I Irrigation 2L> Approx. Depth I I Eastern Surface Seal Installed by _ S� �X•t .,,1� _ Repair Work Done ❑ Type of Pump H.P. —_ State Work Done _ Well Destruction ❑ Well Diameter Sealing Material (top 501 .r Depth Filler Material (Below 501 _ TYPE OF SEPTIC WORK: NEW INSTALLATION 1 I RLI'AIn/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewenis `�- available within 200 feet.) \ O Inst-llation will serve: Residence_ Commercial_ Other V� Nur ber of living units: Number of bedrooms— Ch atter of soil to a depth of 3 feet: Water table depth SEP iC TANK L) Type/Mfg Capacity_ No. Compartments PKG. TREATMENT PLT. ElMethod of Disposal 2 Distance to nearest: Well_ Foundation Property Line l �+ LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED Cl Distance to nearest: e11_ foundation Property Line SEEPAGE PITS I I Depth Size _ Number SUMPS Ll Distance to nea'f'est: Well Foundation Property Line 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 Mtrict. 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, 1 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 California." r 1 I C!�i MCT SAN )t)AQUIN I-CCf�I_ HEALTHT�. The applicant m s call for all qu wed inspections. Complete drawing on reverse side. E(�I��1j7��,Ih.�(N f,�_ I I�r i_f I I !ISI'-11��1 .1' �J;�✓'� Title: (+ /� Signed X iV' l��[ G ,/ FO"EPARTMENT USE ONLY Application Accepted by _ �. Date !-J-C�� Area ,.., Pit or Grout Inspection by Data Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 IFEE NFO AMOUNT DUE AMOUNT REMITTED C K RECEIVED BY DATE PERMIT'NO. r ♦ EH 13.24(REV.I/HS) �tJ ��`-�� a�•^7 .—�[ �� >1 /�/' EH 162EI I I - I\� f ��C%