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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT '� 1601 E. HAZEL i ON AVE., STOCKTON, CA . ` Telephone (209) 466-6781 #, J PERMIT EXPIRES 1"YEAR FROM DATE ISSUED (Complete in Triplicate) a 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 welllpump and the Rules and Regulations of the San Joaquin Local Health District. Job Address IVX I/9tW e/'t 70a'.1 r A1arWV'Y 4VCity 4066 Lot Size *;Z;A4'e5r PM Owner's NameAddress ��/Ll e Phone D _ Contractor Address License No. Phone TYPE OF WELL/PUMP: NEW WELL WFLLREPLACEMENT DESTRUCTION ❑ 1 PUMP INSTALLATION)< SYSTEM REPAIR ❑ OTHER 0 - DISTANCE -DISTANCE TO NEAREST: SEPTIC TANK /Sa SEWER LINES DISPOSAL FLD. PROP. LINE ��` J FOUNDATION1J AGRICULTURE WELL OTHER WELL PITS/SUMPS Z60 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of_Well Casing ;dbomestic/Private ❑ Gravel Pack El'Tracy Type of Casing eae_. _ Specifications /da M 1 Public Other C-] Delta Depth of Grout Seal fere ` Type of Grout �O -; i I Irrigation . - � pprox-Deptfi- I-Eastern Snriaee�Seat-tnstalfed _ Repair Work Done ]C Type of Pump �'ztd_ H.P. 1-___ State Work Done_ Well Destruction ❑ Well Diameter Sealing Material (top 5011.. Depth - Filler Material {Below 50 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION i 1 (No septic system permitted if-public sewer is �1•,r available within 200 feet.) Installation will serve. Residence— Commercial__ Other Number of living units: Number of bedrooms F Y Character of soil to a depth of 3 feet: Water table Elepth l SEPTIC TANK ❑ Type/Mfg Capacity No. Compartmentsr-IJ PKG. TREATMENT PLT. ❑ Method of Disposal' Distance to nearest: Well Foundation Property Line t I� `LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line_-- SEEPAGE PITS II Depth Size _ Number SUMPS C] Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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 Di%trict. 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 F` 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." -� m - The applicant must II far all equito ingpectLons. Complete drawing on reverse side. Signed Title: Date: A ,l FOR DEPARTMENT SE ONLY Application Accepted by Date Area f I Pit or rout nspection by Date[l Final Inspection by ° Data Additional Comment / 14e C/ ❑ Stk 466-6781 0 Lodi 369-3621 ❑ Manteca 823-71 ❑ Tracy 935-6385 Applicant- Return all copies to: Environmental Healtq Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 9520 FEE INFO AMOUNT DUE AMOUNT REMITTED CA5H RECEIVED BY HATE PERM�IIT'NO. + EH 1026IREv.+/N51 ✓S-w - G.IIt 1+1-�^" ! 12-2-7 -2- nr f