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r APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT / 1601 E. HAZELTON~AVE., STOCKTON, CA Telephone (209) 466-67$1 ' PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete 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 Ryles and Regulations of the San Joaquin Local Health District. ; DY -7►= -L-AZ Job Address Cityl--GUW r Lot Size / PSN' Owner's Name Address 1521LI—l-'H 45#1 ZJA0;;W Phone ..c.. ,. L .+mss....+.. - . Contractor ] c IV Address License No. Phone TYPE OF WELL/PUMP:""" NEW"WEL'L ❑.,` ---WELL REPLACEMM 'rfr bESTk0CTION ❑ ?. PUMP INSTALLATION-❑ t SYSTEM REPAIR ❑ i OTHER ❑ 1 r DISTANCE TO NEAREST: SEPTIC,TANK SEWER LINES , DISPOSAL FLD. PROP. LINE ? FOUNDATION' ' AGRICULTURE WELL 1 OTHER WELL!- PITS'/SUMPS INTENDED USE TYPE OF WELL PRO 8LEM AREA jCONSTRUCTION SPECIFICATIONS t [I Industrial 1 E) Open Bottom ❑"Manteca #Dia. of Well Excavation Dia�of Well Casing F1 Domestic/Private ❑ Gravel Pack" - ❑Tracy_ - ,Type;of Casing Specifications I ❑ Public ❑ Other ❑ Delta Depth of Grout Seal TType of Grout 'd"Irrigation - ---Approx. Depth ❑ Eastern. ,_p Surface Seal installed by Repair Work Done C 'Type of Pump . y 14 H.P;• k State Work Done --,.Well Destruction--L...,r Well.Diameter.. s- Sealing Material ftop 5011 - �-�•- Depth Filler Material IBelow 501 i TYPE OF SEPTIC WORK: NEIN INSTALLATION 0 REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is i available within 200 feet.) Installation will serve: Residence— Commercial Other t Number of living units: Number of bedrooms 3 r Character of soil to a depth of 3 feet: __. Water table depth SEPTIC TANK ❑ Type/Mfg "Capacity No. Compartments _ PKG. TREATMENT PLT. ❑ - Method of Disposal Distance to nearest: Well _ Foundation" Property Line C LEACHING LINE C No. & Length of lines l Total length/size I FILTER BED G Distance to nearest: Wel! Foundation Property Line W SEEPAGE PITS. Depth laS- -Size l �b� "_ Number ' l SUMPS ❑ Distance to nearest: Well Foundation A140/1/E7 Property Line 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 District. ' I 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, 1 shall not employ any,person in such manner as to become subject to workman's oompensation 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." - The applicant must call for all required inspections. Complete drawing on reverse side. ' Signed X/j?'!?GC'e� /4 PG3 c Title:q?-� 1' Date: FOR DEPARTMENT USE ONLY Application Accepted byJJ DateIto Area Pit or Grout Inspection by Date 1 D Final Inspection by ,yJ Date Additional Comments: a'J[ Q.�tk 466-6781 -C Lodi 369-3621 ❑ 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 - FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY. DATE �_f ERMIT.'MO r. .INFO- `-CASH. - + EH 3-24( 14-26 51 �~ t • t'