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APPLICATION FOR PERMIT f SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE i ON AVE., STOCKTON, CA 4 Telephone (209) 466.6781 E� PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Cornplete 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 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. # 1 Job Address ©b ( �� L City imAdtl eco Lot Size PM Owner's Name RUL-GC'/U AddressPhone r { E Contractor l M C��-Gte. Address SO Qk1� ��e License No. `13 1 I Phone 82 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ k` DESTRUCTION El ! 1 PUMP INSTA-CCATION•O TEWREPA'IR-0-II—"-OTHER'171 i a DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE , TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial EJ Open Bottom ❑ Manteca Dia. of'Well'Excavation II. Dia.,of Well Casing J ,r j Ll Domestic/Private ❑ Gravel Pack © Tracy Type of Casing `` Specifications; f`I Public f7 Other {l Delta Depth of Grout Seal if Type of Grout: -- I I IrrigationAeproxi;QePch- -.-C . . ---- c,,,, c .. I - - Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction Well Diameter Sealing Material (top 50') lV, ` a Depth Filler Material (Belo 50 EM y--YPE O'F SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION-IK DESTRUCTION I I (No septic system-permitted if,public sewer'is U ' available within 200 feet.) FGV Installation will serve: Residence- Commercial_ Other , ' Number of living units: Number of bedrooms t Character of srnil to a depth of 3 feet: � � � t P Water table'8epth 7. SEPTIC TANK ❑ Type/Mfg t 1 Capacity k No_ Comuariments 4 PKG. TREATMENT PLT. C) � t I� (Method of Disposal cy Distance to nearest: Well a Foundation I Property Line t kLEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ' j i Distance to near e8t: Well fr rI EFound tion I` Property•Line—� SEEPAGE PITS I I Depth Size _ Number •I"R _ SUMPS Ll Distance to nearest: Well Foundation ll Property Liner ' f DISPOSAL PONDS ❑ ,Y r ip 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. I '11 ' 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 l 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 California." I The applicant must call for all required ins tions. Complete drawing on reverse side. Signed Tiile: t �Vim_ Date: .2'.� .I. F� M_�ENT SE ONLY ,, Applicatioh.Accepted b ; Dater. Area Pit or Grout Inspection by Date Final Inspection b Date'' 2�5 Additional Comments: l� } ❑ Stk 466-6781 '� Cl Lodi ,369-3621— ❑ Manteca-823-7104�l=—i Tracy--835=6385--�^-� -*r••- �-}k»► •*•-�-�--� -- Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk. , CA 95201 d .€I FEE INFO AMOUNT DUE' AMOUNT REMITTED H x RECEIVED BY DATE PERMIT NO. (REV.tin5t EH 14-26 y` E 1 � � `� ��Z b Cr o---5d1