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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA k 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. Job Address (0 ! 0 L City Lot Size PM Owner's Name PA V 15W!Pr�g�I! Address Phone *-•�^,•----. ...�.».--.,...,...- ..,�,�.�.■,,,.,,,�..a..�.,.�, ...�,...,�:-.,.nom �...-,..,�....-..W,..a� ------ �_�.�_ ... .. , Contractor ' r s .' �az e Address 1?Q, /S�9'1�LTi1d License No T�4�SoZ Phone �2 s o TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ i PUMP INSTALLATION ❑ SYSTEM REPAIR © OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE } FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manu Dia.of Well Excavation -e Dia- of Well Casing r ❑ Domestic/Private L1 Grave! Pack ElTracy Type of Casing Specifications ❑ Public F1 Other ❑ Delta ' - Depth,of Grout-Seal Type of Grout I I Irrigation ` _.-Approx. Depth I I Eastern �~ Surface Seal'Installed by _ Repair Work Done ❑ Type of Pump I H.P. State Work Done '- . V61 Destruction ❑ Well Diameter t Sealing Material (top 50') „} - t Depth Filler Material (Below 50') j 4 TYPE OF SEPTIC WORK; NEW INSTALLATION REPAIR/ADDITION f I DESTRUCTION i I (No septic system permitted if public sewer is I/ r available within 200�feet-1 ? O Installation will serve: Residence Commercial_ Other ! x Number of living units: Number of bedrooms _ I �. , �l l Character of soil to a depth of 3'feet: '' A D ' $c Water table depth i SEPTIC TANK ❑ Te/Mf �' Ca 4 Type/Mfg g acit p y�1�_ No. Compartments it PKG. TREATMENT PLT. ❑ Method of Disposal ,Distance to nearest:- - V4Jell Foundation_ Property Line �• � LEACHING LINE No. & Length of lines _FT Total length/size ' FILTER BED LJDistancet to nearest: Wells' �� Foundation /0 7 ' Property Line 7 G •„ t I SEEPAGE PITS l 1 DepthSize a Number ii i -.f SUMPS f Distance to nearest: Well--tca 'Foundation /Q j Property Line 1.2 i I DISPOSAL PONDS ❑ '^ hereby certify that I have.prepared this application an8 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. i Home owner or licensed agent's signature certifies the following: "I certify that in the perforrri66ce 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 P certifies the following: "I certifythat•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 applicanumust call for a quirg inspections. Complete drawing on reverse side. j Signed X I I Title: _ __ T Date: f gFOR DEPARTMENT USE ONLYApplication Accepted by. ' .+ Date 1/ Pit or Grout Inspection by Date Final inspection by Date t 1 �� Additional Comments: ❑ Stk 466-6781 L Lodi 369-3621 0 Manteca 923-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Envirorimental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Sik., CA 95201 FEE AMOUNT DUE �. { AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. .. INFO_ — - --CASH___ - - ._ _�..._._. +Eli -21:13-24:-28 3 rREV.'1 Te 5 EH 13-29 l ....... - ' -s +-tip_