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Y F x �0U . APPLICATION FOR PERMIT ,{ SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 r PERMIT EXPIRES TYEAR FROM DATE ISSUED (Complete in Triplicate) I 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 AnCity Lot Size 7GQG/LG S PM Owner's Name -::�n e- 4,9^A LA Address Iq 10 A Phone =33 Contractor " e Address I , t icense No.�gQ3�3 Phone�� a .,,,,,,r,,,,,TYPE OF WELL/PUMP:_ NEW WELL 19f-- },WI=LL REPLACEMENT ❑ e, _,�tDESTRUCTION 1-1 PUMP INSTALLATIONSYSTEM REPAIR 17OTHEf�❑ d d NJ DISTANCE TO NEAREST: SEPTIC TANK // D- SEWER LINES DISPOSAL FLD.10i9- PROP. LINE A FOUNDATION % AGRICULTURE WELL•" OTHER WELL n 0Ae PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS r R Ll Industrial ' Open Bottom ❑ Manteca Dia. of Well Excavation / Dia. of Well Casing_ Aomestic/Private ❑ Gravel Pack O Tracy, Type of Casing S' �� , Specifications F] Public n Other F1 Delta Depth of Grout Seal Typg of proul t r2��_A rox. Depth { I Eastern Surface Seal Installed b l/-.t t I I Irrigation pp Y pp - Repair Work Done ❑ Type of Pump _ 14.P. , State Work Done r Well Destruction ❑ Well Diameter Sealing Material [top 501 ` Depth Filler Material (Below 501 TYPE-OF-SEPTIC WORK:-NEWANSTAL•L-ATION.[-) REPAIR/ADDITION,(,.(_DESTRUCTION-(1-INo-septic_system"permittedif.public.sewer is available within 200 feet.) Installation will serve: Residence— Commercial— Other 0 _ Number of living units: Number of bedrooms - I Character of soil to a depth of 3 feet: Water table depth f SEPTIC TANK ❑' Type/Mfg t, Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal f - "Distance to nearest:/. Well Foundation Property Line ! LEACHING LINE ❑, No. & Length of lines Total length/size 1 p FILTER BED: a ❑. Distance"tonearest: ell � ' - ' Foundation f Property Line SEEPAGE PITS I 1 Depth •° Size, 1Number SUMPS Lla Distance to nearestr Well` Foundation Property Line "" DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will be done it accordance with San Joaquin county ordinances, stale laws, and rules and regulations of the San Joaquin Local Health District. I f 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 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 ompensation laws of California. The applicant lmuus call for-all required inspections.„Comptete drawing on reverse side Signed X� /[ � to Jl Jt.t Title: �. /A--p 5- Date: FOR DEPARTMENT USE ONLY I ,Application Accepted by Date Area i Pit or Grout Inspection by Date a Final Inspection by Date 6 i � 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 , s F INFO AMOUNT DUE AMOUNT REMITTED CASH KRECEIVED BY �D'ATTE PERMIT'NO. a EH 13-24(REV.t K 5) EH 14-26