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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON ON AVE., STOCKTON, CA I€ Telephone (209) 466-6781 PERMIT EXPIRES 1'YEAR FROM DATE ISSUED {Complete in Triplicate) 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. NQ (,Gs�. �r +r4 ✓_ /� Job Address Y ' • 0 L City ''i CV ' Lot Size I PM a r� Owner's Name � Z�JPFACE Address Zl18 �,Hr("N d rE., /1�/4C� Phone 17 ConiracioriQ1L.LI �LrC.AddressP-d-8. CLiL�eenseso. X 33783 ��Phone2 r«7 S r i TYPE OF WELL/PUMP: NEW WELL EV WELL REPLACEMENT ❑ DESTRUCTION ❑ /i'16Ri`�i nJ I PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER C-"• DISTANCE TO NEAREST: SEPTIC TANK -,.�� SEWER LINES DISPOSAL FLD. PROP.'�LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS ' INTENDED USE TYRE OF WELL PROBLEMAREA CONSTRUCTION SPECIFICATIONS ❑ Industrial 1-1Open Bottom C1Manteca Dia. of Well Excavation Dia. of%A ell Casing LV/Domestic/Private 19/Gravel Pack ❑ Tracy Type of Casing PV C Specificatiions j t I`l Public f Other I l Delta Depth of Grout Seal Type of Grout + ? I I Irrigation 1"..Approx. Depth I ] Eastern Surface Seal Installed by lM ? Repair-Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material Itop 50') II ` Depth Filler Material (Below 501 (( 44 TYPE OF SEPTIC WORK: NEW INSTALLATION I1 REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is "? F available within 200 feet.) 6 Installation will serve: Residence_ Commercial_ Other I I Number of living units: Number of bedrooms I { Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. 71 Method of DisposJ 1 . I Distance to nearest: Well Foundation Property.Line ` LEACHING LINE ❑ No- & Length of lines Total length/size-- FILTER ength/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number IM SUMPS Cl Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I � I 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 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 hiring orr 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." The appl-ca mus call for all required in pectin s.-Com drawing on reverse side. Signed X lets Title: fA-61AJ W. P Date: I z FO D PARTMENT USE ONLY S Application Accepted by Date " _ Area 3 x Pit or Grout Inspection by DateFinal Inspection by I�. Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 04 Tracy 835-6365 Applicant - Return all copies to: Environmental Health Perm- Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE y AMOUNT REMITTED CK RECEIVED BY DATE PERMIT-IVO. EH-53-24 IREV-r/r+5) �� >EH i4-26"+• - dam"'/ ' 'i