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'i APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE I ON AVE., STOCKTON, CA y.. Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR.FROM DATE ISSUED try 4 (Complete in Triplicate) I ' 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.GY�L�� Job Address cl�1a city f �' Lot Size PIM 1� ' l l L i �s� 5.��1� 1"IQ 0 `kPhane`C Owner's Name �QrR � l�� Address ` Contractor•-r`n-r�54- Sys Addre..4),r1- �rX Z] :5 -c- '^'L=icense NOS5-3 6 y s� PhoneLiis.-LILi TYPE OF WELL/PUMP: NEW WELC15, WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLAT10�1 ❑� SYSTEM REPAIR LJ OTHER El DISTANCE TO NEAREST: SEPTIC TANK ��2SEWER LINES DISPOSAL FLD. PROP. LINES..._ t FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF.WELL PROBLEM AREA CONSTRUCTION SPECIFICATIO(VS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavat' n �� Dia. of Well Casing 6 Domestic/Private .Gravel Pack El Tracy Type of Casing C- ass 4 Q Specifications r + ❑ Public ❑ Other 'Delta Depth of Grout Seal Type of Grout .T' ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by On; � �5 ! Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material Melow 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is 'I available within 200 feet.) Installation will serve: Residence! Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg CapacityNo. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal f Distance to nearest: Well Foundation Property Line 'l " LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line I SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 4 r 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 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 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 C omia." The applican t tali fo req 'red inspeAions. Complete drawing on re erse side. Signed Title: Q ' `t r Data.. j I FOR DEPARTMENT USE ONLY (). Application Accepted b Date �� Area Pit or Grout Inspectio Date Final Inspection by Date q Additional Comments: J ❑ Stk 466-6781 ❑ Lodi 369-3521 ❑ Manteca 623-7104 ❑ Tracy 8354i385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. INFO } a' + EH 13-24(REV.1/85) (] �•'p ��i7 ^�- 1�1 s7- Stj EH 14-28 v _ , S `