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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELT-bN,^A`•VE., STOCKTON, CA i - Telephone {209] 466-6781 ., I PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) 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 Rules and Regulations of the San Joaquin Local Health District, ri s i . Job Address City Lot Size PM Owner's Name --' C,r l)t .Address Phone Contractor %.^—hr '`-"- 5� aAddress Y_300 67 + License No. Phone + TYPE OF WELLF/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ 1 PUMP INSTALLATION ❑ SYSTEM REPAIR❑ O�liER DISTANCE TO EARESF:S DTIC TANK- - SEWER LINES 4 rDISP_OSAL,.ELD?� PROP. LINE {J� eFOLINDATION'""""_ AGRICULTURE,WELL OTHER WELL PITS/SUMPS ` INTENDED USE TYPE OF WELL. PROBLEM''AA CONSTRUCTION SPECIFICATIONS t\t ❑ Industrial ❑ Open Bottom'�"� ❑,�Man�. f�. Dia�of=Well=Excavation-�_ - - --D,ia�of Well Casing r E �Damestic/Private ❑ Gravel Pack H-Tracy,4 Type of Casing �l Specifications k ❑ Pubh, 11 'Other ❑ Delta Depth of Grout Seal Type f Grout w ; k 1S a.+_#�- rrigation �pprox: De-th'. ❑Eastern urface Seal Installed bypair Work Done ❑ Type of Pum i, + �I LP: State Work Done # �v I { Well Destruction! ❑ Well Diameter °"Sealing Material (top 50') r Depth � Filler Material {Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION:,Q (No septic system p`ertr fitted if public$ewer is Q { r� % available wit f 200 feei.} G Installation will serve: Resideilceommercial��Other r ''� rNumbe o bedrooms Number of living units: rCharacter of sail to a depth of 3 feet: AdDb�- - Water table,de�pth S�E.PTIC TANK ❑ -TypJMfg Capacity No. Comparfinen s PKG. TREATMENT PLT .❑ ar Method of Di spo I } + Distance to ne"arIs t: Well Foundation Property Line1 s s v LEACHING LINE E3A6. & Length oIst: fines Total length/size ' ' FILTER BED ❑ Aistanee to�rrea Well Foundation .+"r Property Line I �SEEPAGE PITS ❑ Depth Size NOmber S MPS ❑ Distance to nearest: Well N_ Foundation Property Line r IynDI,SPOSAL PONDS Cl thpwby certify!hat I have prepared this application and that the work will be done in accordance with San Joaquin coup ordinances, sate laws, and rq'les and regulations of the San Joaquin Local Health District. ` Home owner or�icensed agent's signature certifies the following: "I certify that in the performance of theVorrk for which tf is permit is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws ofi<a1'rfotnia�;hContractorsshlrrn or sub-contrasting signature i' rsorls ject to workmah's cords nsa- certifies the following:"I certify that in the performance of the work for which this permit is issued,l shall em�loy'�e tion laws of Caliyfornia." i The applicant must li for all r d ins IQ . Complete drawing on reverse side. I -" ;Signed TiTtle: Dat . FOR DEPARTMENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection by Date _ Final Inspection y Date r � Addi //�i itional Comments: �,�, l J' Stk 466 6781 ❑ Lodi 369-1 ❑ Manteca 823-7104 . ❑��racy ,835-6385 'Ap nt= Retu n a6 copies to: Environmental Health Permit/Services 1601 E.'}iazelta�4:i;-P_.d.".Box 2009, WK., CA 9u201 t r INFO AMOUNT DU AMOUNT AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT`NO. +EH f3.24 r,1REV.1/e51 ^t, lly ��`Vy�j; F e •. `L^�JU U'Vr . EH 1426 l ►. \ } ✓.'k`�: j `�_ _. - � _ ` lir � `']iy-+"R .`"r �, r � � �'•''�,34• y .