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APPLICATION.FOR PERMIT ` SAN JOAQUIN LOCAL HEALTH DISTRICT t 1601 E. HAZEL T ON AVE,.STOCKTON, CA Telephone {209) 466-6781 ' 111" • PERMIT EXPIRES 1 YEAR FROM.DATE ISSUED t (Complete in Triplicate) r V _ F,, • .�� ,., , 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 RulesaridRegulations of the San Joaquin Local Health District. f � ,f Job Address j� 1 �j .' i '1/" S f f to _ City hG O ++ 'Lot Size PM Owner's Name '7 Address �G � '� �r �Y Phone �� !� f� � Contractor d �'Addre 3 W l L 4 r L f►{ � U�� License No. Phone TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP I.NSTALCATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL fPRO�P- LIMNE FOUNDATION AGRICULTURE WELL ER WELLS INTENDED USE TYPE OF WELL PROBLEM AREA TRUCTION SPECIFICATIONS I ❑ Industrial ❑ Open Bottom ❑ Ma Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal T LJ Irrigation pprox. Depth C1 Eastern Surface Seal Installed by - - Type of Grout r Repair Work Done Type of Pump H.P. State Work Done_ -A 4 JJ Well Des on ❑ Well Diameter Sealing Material {top 501 Depth i — - — -Filler Material-(Below-50'1 TYPE OF SEPTIC WORK: NEW,INSTALLATION ❑ REPAIR/ADDITION ❑'ti DESTRUCTION. INo septic system permitted if public sewer is available within 200 feet.)} i E Installation will serve: Residence Commercial_ Other _ ? Number of living units: z Number of bedrooms ^rr ) ke € t Character of soil to a depth of 3 feet:j :-Water table depth I' SEPTIC TANK X Type/Mfg Ca acit p Y No. Corfipartments PKG. TREATMENT PLT. ❑ Method of Disposal-- V Distance to nearest: Well Foundation Property Line j LEACHING LINE E1. No!& Length of fines Total length/size FILTER BED ❑., Distance to nearest: Well f Foundation Pr } operty Line SEEPAGE PITS Depth Size Number I r SUMPS ❑ Distance to nearest: Welt Foundation Property Line DISPOSAL PONDS Li }LPC I hereby certify that I have prepared this application and t'a the work will be done in accordance with San Joaquin county ordinance's, state laws, and rules and regulations of the.San Joaquin,Local,HealthDistrict. r ` 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." Contractoes hiring or sub-coritracting 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.". s= Th plicant m all for all re r s ti s. Complete drawing on rev rse side. o i Signed � Title: Date: ' # ! to OR DEPARTMENT USE ONLY Application Accepted b'y Date v Area Pit or Grout Inspection by t E 4 Date Final Ins action b P y Date 5) Additional Comments: J2710 ❑ Stk 466-6781 O'Codi' 369-3621 ❑ Manteca 823-7104 . ❑ Tracy 835-6385 ( Applicant - Return all coples,to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 o M "INFO -o-AMOUNT:DUE»-� --= AMOUNT REMITTED " K ° RECEIVED BY DATE PERMIT'NO. 4��S_§+ EH 13-24(REV._/h 51 f 4 ,r i. ° r/- n^ ` 7 � 1 EH 1428 L•1/' `/J{i ...7 3.,. 1 .a.... _ .p _ .. . I