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APPLICATION ,FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM PDIATE ISSUED �a ., (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 H compliance with San Joaquin County:Ordinanca No. 549 for sewage or No. i862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. A�X f�01C Job Address � ' City Lot Size PM Owner's Name r + Address Phone 1i7 OF DIST. --- - Nrvv VVtLL LJ WELL REPLACEMENT 0 PUMP INSTALLATION ❑ bESTRUCTION ❑ 6'- SYSTEM REPAIR ❑ OTHER ❑ E TO..NEAREST:,,SEPTIC,TANK SEWER -LINES— =�.- _ - !. FOUNDATION -- DISPOSAL _ _PROP. LINE _ AGRICULTURE WELL' OTHER WELL PITS /SUMPS _..DED=USE TYPE OF•WE( 1 ❑ Industrial t'i'Q.Open Bottom 0 Domestic/ Private Ll Gravel Pack ❑ Public 1 1 ❑ Other ❑ Irrigation ---Approx. De Repair Work Done ❑ Type of Pump _ Well Destruction -i ►nioG Depth 0 PROBLEM AREA CONSTRUCTION: SPECIFICATIONS ❑ Manteca Dia, of Well Excavation' � L. t ` Dia. of Well Casing ❑ Tracy Type of 6sing ❑ Delta !� t -- Specifications Depth of Grout Seal Type of Grout ❑ Eastern Surface Seal Installed byte It State Work Done -r— Sealing Material (top 50'1 Fillers Material -{.Below-50=}-.•-- 1 Trt UFISEPTIC WORK: NEW INSTALLATION EPAIR/ADDITION ❑ DESTRUCTION ❑ `('No septic sysieni, permitted if public I Installation will serve: -Residence.. ' Commercial available within 200 feet.} Other i _P Number of living units: Number Qf bedrooms I Character of soil to a depth of 3 feet: t SEPTIC TANK Water table depth F 's—'sC PKG: TREATMENT PLT.`❑ Capacity_IC r�No. Compartments Distance to nearest: Well Foundation1�. ,Method of Disposal s Property Line LEACHING LINE moo. & Length of lines c Total length/size A ` FILTER BED ❑ Distance to nearest: WellI ► Foundation Property Line SEEPAGE PITS{ 7 Depth Size Number P SUMPS # b Distance to nearest: Well Foundation' DISPOSAL PONDS ❑ Property Line herebyprepared ^ � • certify that I have re ared this and that the work will be done in accordance with San Joaquin county ordinances, Istate laws, and rules and'regulations of the San Joaquin Local Health District, Home owner or licensed agent's signature certifies the following:► employ an "I certify that in the performance of the work for which this permit is ued, I shall not I P Y Y person in such manner as to become subject to workman's compensation faws'of California.'1Contrac. r' hiring or sub -cont . racting signature f certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall em to on laws f California. p y persons subject to workman's comperisa The a P ust call fo If req d ins tions. om ete dra r wing on verse std t Sign - Title: t AI Date: , FQR DEPARTMENT�:U�U�dNLY y Jill Application Accepted by Data Pit or Grout Inspection by !1 y F Date Final Inspection by � Additional Comments; " "ID-Stk-466-B781-------a-L•odi--369-3611- -----p=Manteca--823-7104------p-T-m cY--835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E.Hazelton Ave ;'P O: -E ---p; V . F i j 2009, Stk., CA 95201 Date d FEE' AMOUNT DUE AMOUNT REMITTED CK INFO f ,rSH RECEIVED BY±DATE PERMIT TIO. ' E EH 124 (REV, 70183E �1 ! d � � &L) EH 144-26 �-!1 jJ' '11j �/ 4 f