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I M APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone 12091 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) i Application is he"eby 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, I Job Address /_ w „(�//l;Z&e 40 J City y Lot Size PM Owner's Name Address Phone Contfactor V� f�i /"ZJLL-GK�_fAddressLicense Nt h _Phone I TYPE OF WELL/PUMP: NEW WELL E] WELL REPLACEMENT L1DESTRUCTION 0 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES- DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE,WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL., ,4 PROBLEM AREA CONSTRUCTION SPECIFICATIONS D Industrial i❑ Open Bottom *° .t ❑'Manteca'` -Dia. of Well Excavation Dia- of Well Casing ❑ Domestic/Private ❑ Gravel Pack ✓❑ TracY Type e of Casing:.� 9 Specifications ❑ Public ❑ Other 171 Delta Depth of,Grout Seal. Type of Grout I i Irrigation dep— --!--Approx. Depth; I 1 Eastern x 5uriace S I Installed by Repair Work Done ❑J Type of Pump "F['p: State Work Done Well Destruction ❑ Well Diameter Sealing Material Itop 50') r Depth i Filler Material (Below�50�) s TYPE OF SEPTIC WORK: NEW INSTALLATIONREPAIR/ADDITION I i DESTRUCTION I I INo septic system permitted if public sewer is I available within 200 feet.) Installation will serve: ResidenceCommercial— Other ;c j ti : t Number of living units: —I-- Number of bedrooms Character of soil to a depth of 3 feet: t Water table depth SEPTIC TANK ❑ Type/Mfd� z Capacity F No. Compartments PKG. TREATMENT PLT. ❑ �f-�- ``. Method of Disposal Distance t I nearest:' Well Foundation " ' ear ��..Property Line ��' r7— ,0 ` . ! LEACHING LINE t Na. & Length of lines 1� Total length/size ,* FILTER BEDC1 Distance to nearest: Well 4" Foundation Tom= property Line- �U „s SEEPAGE r �.�. 7 PITS ( I Depth Size _ Number a SUMPS ❑ Distance to nearest: Welt Foundation Property Line A M DISPOSAL PONDS ❑ a - 'f'• r .y �l 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 Di%trict. -` 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 4 v employ any person in such manner as to become subject to workman's compensation 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 al requir nspections. Complete drawing on reverse side. I Signed X Title: _ 4 Date: __l I IWI Jor FOR DEPARTMENT USE ONLY Application Accepted by Date f t° Area t Pit or Grout Inspection by Date Final Inspection by Date l� Zr� Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 0 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 95201FEE t` rINFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. 07 EH IT24(REV:t i tis) ANA-11-1