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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 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 R41es and Regulations of the San Joaquin Local Health District. Jab Address �I 69 City Lot Size PM Owner's Names f Address I bgA1 -369 Phone —`51q? Contractor $r �+ Address jy� °� � License,No.11CV1 t5 -I—Phone --.-TY-PE-OF WELL/PUMP:-—,MEW-WELL tj-- - WELL REPLACEMENT -'"" AESTRUC710TV"❑,_ -- f" ' PUMP INSTALLATION C g SYSTEM REP IR ❑ OTHER ❑ 'DISTANCE TO NEAREST: SEPTIC TANK _.-:,-SEWER LINES DISPOSAL FLD.QD PROP. LINE FOUNDATION _ GRICULTURE WELLIJK: OTHER WELL_IfX7 PITS/SUMPS f INTENDED USE' �. TYPE-OF WELL�PROBLEM AREA CONS R CTION SPECIFICATIONS Q ❑ Industrial Open Bottom ❑ Manteca .Dia. of Well.Excavatio�n� ` f Dia. of Well Casing V Domestic/Private , ❑ Gravel Pack, r ❑ Tracy Type of;Casing- -sem` ` - Specifications x❑ Public j ❑ Other ❑ Delta Depth of`Grout Seal r �Typeofrout `r. �❑ Irrigation --Approx. Depth--.a Eastern Surface Seal Installed by 'Repair Work Done ❑ Type of Pump. *' H.P. State Work Done Well Destruction ElWell-Diameter- "" �' Sealing Material (top 501 f •`Dep}h'^ -Filler Material (Below 50') STYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ Mo septic system permitted if public sewer is available within 200 feet.) 4 Installation will serve: Residence_ Commerciale-i Other 4 Number of living units: Number•of bedrooms Character of soil to a depth of 3 feet: ' Water table depthA- PKG. SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments TREATMENT PLT. ❑ 't ' Method of Disposa Dista ce to nearest; Well Foundation Property Line LEACHING LINE ❑ Nr)-&�tength of lines �` Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line y SEEPAGE PITS ❑ Depth _Size Number SUMPS ❑ Distance to nearest: Well Foundation Property,Line DISPOSAL PONDS. F]I hereby certify that 1 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. a 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." The applicant call for J�equir inspec's . Complete drawing on reverse si . `� /� �, {� Signed i e: Date: FOR DEPARTMENT USE ONLY Application Accepted'by {. Date Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ Stk 466-6761 ❑ Lodi 369-3621 ❑ Manteca -7104 ❑ racy C]h �,� Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., Co 520 ` FEE AMOUNT DUES _—AMOUNT REMITTED CK —.RECEIVED BY.F — —DATE—,,.. PERMI7`'NO. INFO --- _-CASK'`- + EH 13-241REV.1/051 �� Qb 0L1 EH 1426 r