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' APPLICATION FOR PERMIT O SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone 12091 466-6781 I �_ 1 P 1088 PERMIT EXPIRES1 YEAR FROM DATE ISSUED (Complete in Trjplicatel - ENVIROMENTAL HEALTH' iE . . M - 4FERMIT/SERVICES _,. 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 Ryles and Regulations of the San Joaquin Local Health District. ; „< .,.. E4 ,..,a :� . . . ., i . .. _ „ %J .. -1 ,i Job Address 46' aee City Lot Size PM iI Owner's Name Address./&M Phone ! , 1� el Contractor Address[f 7/7-L�Y�G &:*id&License No��PhoneQ_59 Y°,0, TYPE OF WELL/PUMP: NEW WELL El .- WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER DISTANCE TO NEAREST: SEPTIC TANK F SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS q ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing IN Domestic/Private' ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 171 Public Ll Other (71 Delta Depth of Grout Seal Type of Grout 11 ❑ Irrigation ---Approx. Depth ❑ Eastern LLSurface Seal Installed by Repair Work Done IType of Pump A-1 H.P. /WL` S ate Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 ; VV Depth Filler Material {Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION Cl DESTRUCTION ❑ (No septic system permitted if public sewer is C available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms Ti Character of soil to a depth of 3 feet: 'g r .j ti Water table depth I SEPTIC TANK -L].. Type/Mfg w_ - ..2...-J PKG.-TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation - Property Line LEACHING LINE _❑ No. & Length of-lines Ij Total lengthlsize" i FILTER BED ❑ Distance to nearest: well. RFoundation Property Line SEEPAGE PITS ❑ Depth Size 1 Number Ii SUMPS ❑ Distance to nearest: Well Foundation Property Line - FDISPOSAL PONDS ❑ 9i 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 compensa#ion laws of California." Contractors 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 E The applicant must call for II r uired inspections. Complete drawingo rse side. Signed Title: iYiL�c.r Date: FPR EPARTMENT USE ONLY ' i, Application Accepted by Date Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ! ❑ Stk 466-6781 ❑ Lodi 369-36211 ❑ Manteca 823-7104 ❑ Tracy 835-6385 s Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Bax 2009,'Stk., CA 95201 IFEEK NFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT"NO. !r + EH 13-241REV.7/95} EH 1426 ; , it