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APPLICATION FOR PERMIT - SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 'I 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 (3 9So /IF, Lrld01,13�f :i" _._ CityLot Size PM Owner's Name tt`ljrl'.Ci Z&2_-Md✓d o! //, /6' Xddress S�j}, T Phone Si 57 Contractor's Name f'/,L'/%s/5/ SiD License No. .91 SV"-.7'V_7 Phone 46- 9 n TYPE OF WELL/PUMP: NEW WELL D WELL REPLACEMENT ❑ DESTRUCTION n PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL. PITSISUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Li Industrial ❑ Open Bottom i 1 Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private D Gravel Pack ❑ Tracy Type T i of Casing . . __ Specifications _ .. u_Public N f- Other ❑ Delta Depth of Grout Seal Type of Grout r d lirigation ---Approx. Depth ❑ Eastern Surface Seal Installed by __ Repair Work Done L7 Type of Pump H.P. ` State Work Done Well Destruction ❑ Well Diameter __ Sealing Material (top 50') _ Filler Material (below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION C DESTRUCTION ❑ (No septic system permitted if public sewer is h available within 200 feet.)'- -- - -V1• Installation will serve: Residence_ Commercial Other Number of living units: _ Number of bedrooms f Character of soil to a depth of- A�43 feet: J_ 0 /C L1}i'1 Water table depth 6 !� SEPTIC TANK C-' Type/Mfg 4�w.,vp i? Capacity-:?.V-00 No. Compartments PKG. TREATMENT PLT. LL f Method of Disposal Distance to nearest: WellI Foundation,ZfL__.. Property Line /VO o LEACHING LINE ❑ No. & Length of lines Total length/size- fZ K / 9L _ FILTER BED IirooeDlstance to nearest: Well .ZDV Foundation Property Line /O&4 � SEEPAGE PITS ❑. Depth Size Number ` SUMPS ❑ 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 District. Home owner or licensed agent's signature cartWws the following: "I certify that in the performance of the work for which this permit is issued, 1 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 laws of California." 1. .-, r.- - The applicant t call for all required inspections. Complete drawing on reve side. Signed 2 �j Title: .__ Date: FOR DEPARTMENT USE ONLY AppVcation Accepted by �,\ Date AG_4 Area Pit or Grout Inspection by Date Final Inspection byDate + �1 Additional Comments: I � ❑ Stk 465-6781 (D-Lodi 369-3621 El Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies-lo:-Environmental Health Permit/Services 1601 E. Hazehon Ave., P.O. Box 2009, Stk., CA 95201 r A FEE INFO AMOUNT DUE AMOUNT REMITTED ' ASH RECEIVED BY DATE PERMIT'NO. *a 114-26late.to%ate