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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL'HEALTH DISTRICT .} W. F 1601 E.,HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES I 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 Rules and Regulations of the San Joaquin Local Health District. N .. '.1,'. `- �. _{ y 1 rrl- (4 1• -.:5 Job Address V 1' fX3 f4�1 ls'�xR,�_ btq f`�1V'` `yLoFt Size " c �' C PM QQ I u[ ' » 414 ) ;yT�.� r Owner's Name .1 ,` •;`1�IG C' Address"-_300-7= ` / I/-5' ��. Phone / XV Contractor:T�&4�" Address._!5Q3 ItOA:Lr Jb-t- LicenseNo. 35bzS9 Phone 8 qZ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION y�. 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 PROBLEM AREA CONSTRUCTION SPECIFICATIONS kIndUStrlal ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing X Domestic/Private ❑ Graiel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout n ❑ Irrigation ---Approx. Depth ❑ Eastern I Surface Seal Installed by Repair Work Done ElType of Pump 'T-7,M— N.P. k �7- �y� _ State Work Done PIMP 7;alraceA11 Well Destruction ❑ Well Diameter Sealing Material (top 50'1 Depth Filler Material IBelow 50') TYPE OF"SEPTIC WORK::,.NEW-,INSTALLATION-E] . REPAIR/ADDITION ❑ .DESTRUCTION ❑ (No septic system permitted if public sewer-is-.- available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: 'Number of bedrooms r 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 J I LEACHING LINE ❑ Not& Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line r r , SEEPAGE PITS ❑ Depth "Size " Number " SUMPS ❑ Distance to nearest: Well Foundation 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. 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 w certifies the following:"I certify that in thlions. ormance of the work-for-which this permit is issued, I shall-employ persons.subject to workman's-compensa- tion laws of California." The applic t II for all it i Complete drawing on side. z ► Signed Title: I 45 Date: L2 14 ke S� FOR DEPARTMENT USE ONLY Zj Application Accepted by Date Area Pit or Grout inspection by Date Final Inspection by" Date f } t dditional Comments: 04stk 466-6781 ❑ Lodi 369-3621 x ❑ Manteca 823-7104 El Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. -Box 2009, Stk., CA 95201 FEE INFO AMOUNT,DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT "N0. ! 13-24(REV. EH 14-26