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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA \ Telephone (209) 466-6781 PERMIT EXPIRES 1'YEAR FROM DATE ISSUED O '&?30 .(Complete in Triplicate) y 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 N 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. .( � o.IP`41-e--6 _4CAkilso \ APA) 1 c79 —0,5_0— 09 S.11. Job Address W E bF �J {— JAJIZA � r 401eZ617t7W Lot Size PM Owner's Name f1"t�tL FA / L� Address D3 s 1�'+� Ce4 Z c� a Contractor h�T12c�+n f ress_� `a 46r MY2TZe 57: License No,.r 2-66 Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ 1, PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER)K 3 T'ja^ST 13prZ4p, 9. DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINEt FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ - ell INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Fr�eeifeeafierrs E [-I Public F-71Other 171 Delta Depth of Grout Seal Taapt}dF6reet ft I i Irrigation --Approx. Depth I I Eastern Surface Seal Installed by fl7u L On-�1 Repair Work Done ❑ Type of Pump H.P. State Work Done _ y'''I" Oftc-y— I,(- Well Destruction O Well Diameter Sealing Material (top 50') _ 0iftL.6 a• f_ 1/� Depth Filler Material (Below 50') &1Q TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION i.I DESTRUCTION I I (No septic system permitted if public sewer is i.Commercial available within 200 feet.)Installation will serve: Residence_ — Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: ' Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ 1 Method of Disposal Distance to(nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth + Size Number SUMPS D Distance to nearest: Well Foundation Property Line O DISPOSAL PONDS ❑ 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 Diatrict. 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 California." I The applicant must call for all r fired inspections. Complete drawing on reverse side. D /Y--W-90 Signed X�, Title: T_�0�7LGT 6A,0�0$d sr Date: OR i DEPARTMENT USE ONLY, Application Accepted by Date- r Area Pit or Grout inspection by Data Final Inspection by Date Additional Comments: f ❑ Stk 466-5781 ❑ Lodi .369-36211 Cl Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave.,.P.O. Box 2009, Stk., CA 95201 IFEE NFO AMOUNT DUE ! AMOUNT REMITTED C SH RECEIVED BY DATE PERMIT'NO. + EH1 -24IREV.S/xsi EH 14-26 i�