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APPLICATION,FOR PERMIT SAN JOAaUIN.LOCAL HEALTH DISTRICT G 1601 E. HAZELTON AVE., STOCKTON, CA Telephone 12091 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 we11/pump and the Rules and Regulations of the San Joaquin Local Health District. �� Job Address _ 3-Z'J azeo S..�.-�T CRY `-'r (92 Lot Size Z PM Phone Owner's Name - , Address Contractor c - Address� �- License No. Phone f,TYPE OF WELL;PUMP: WELL G WELL REPLACEMENT ❑ r, DESTRUCTION ❑ + PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ k DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL % " PITS/SUMPS I_fl INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS --3 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of We(using -D Domestic/Private El Gravel Pack El Tracy Type of Casing _ Specifications .,` ! Public ❑ Other 13 Delta Depth of Grout Seal Type of Grout t; ' ❑irrigation _-Approx. Depth 0 Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump• H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material(top 50') Depth Filler Material(Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION O REPAIR/ADDITION DESTRUCTION -i (No septic system permitted if publicsewer is available within er Installation will sve: Residen e= Commercial_ Other ' ' Number of living units: Number of bedrooms�— gAe- { + Water table depth i• Character of.soil to a d of I8 feet:, `i SEPTICiTANK ❑ Type/Mfg Capacity No. Compartments i ` PKG. TREATMENT PLT. C1a Method-of Dsposal ! 1 Distance to nearest: Well Foundation Property Line LEACHING LINE-" "-L �'No. & Length of lines � Tota!length/size FILTER BED ❑4-Distance to nearest: Well Foundation Propend'Line (. 4 SEEPAISE PITS ,� Depth ' Size. Number SUMP9f; ❑ Distance to nearest: Well 14CJ foundation '/ca Property Line C5 ADISPOSAL PONDS O ` ' i !� I hereby,certify th3t^t'have pre¢ared this application and that the work will be done in accordance with San Joaquin county ordinances,nate laws, and j rules and regulations of the San Joaquin Local Health District. ' iHome 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 6rAploy 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- ' ij tion laws of Califo la.' '- 1 The applicant ust 11 to all requir inspections. Complete drawing on reverse de. �rt1e: Date: Signed X FOR f)EPART T USS ONLY �. r /` Areaa Application Accepl�d�b_y`�_. Date f . � Pit cr Grout Inspection by .Date_ Final Inspection by Date ` r Additional Comments: r r - ❑ Stk 4%-6781 t :C Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 8355-6385 Applicant . Return all copies to: Environmental Health Permit/Services 16 01 E. Hazelton Ave., P.O. Box 2009, Stk, CA 9E�201� FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. r INFO .EH t124 4REV.1,!i 5i `7'�. O O 31.3 EH 1426