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yTy .r APPLICATION FOR PERMIT f M SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.YgAZELTON �,,VE., STOCKTON, CA ' Telephone 12091 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 Rules and Regulations of the San Joaquin Local Health District. li Job Address _ C /- '4 � � S '�, �+_ , _ 1 ��}��'9� � } �,, /�.� •pCity Lot Size PM Owner's Name /�C21 i 4 0 Address _Z��C 49 -C� ��_..._ Pho 02, `"T Contractor Address-- icense No.�Phone TYPE OF WELL/PUMP: NEW WELL �W -WELL REPLACEMENT)? DESTRUCTION S L-II sem/ PUMP INSTALLA ION a.. SYSTEM REPAIR ❑ ��O�`TT�HER,A, ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES Z Q DISPOSAL FLD. y PROP. LINE FOUNDATION AGRICULTURE WELL ARA01,00THER WELL PITS/SUMPS "z4v II INTENDED USE�TXPE.OF.WELL- PROBL_ EMP�REA CONSTRUCTION SPECIFICATIONS It A Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well'Casing ❑ Domestic/Private I Gravel Pack ❑ Tracy Type of Casing , Specifications—ZZ . ❑ Public LJ Other Delta Depth of Grout Seal �]-r Type of Gout 14 FJ Irrigation I M-5—Approx. Depth ❑ Eastern Surface Seal Installed by 5 _ Repair Work Done ❑ Type of Pump _ H.P. State Work Done .C/ �`,r "� Well Destruction Well Diameter ' I n I I }dP fi �s Sealing Material hop 50'1 i I 1! Depth /�01II- .— riiler Material (Below 50'1 = 1 TYPE OF SEPTIC WORK:--NEW INSTALLATION ❑I REPAIF#hADDI.TION ❑ DESTRUCTION ❑ {Nd septic system permitted if public sewer is available within 200 feet.) Installation will serve: IAWsidence— Commercial( iher Number'of I"Irv, units: _- Number of bedrooms r! fr i { r v �. Character of\soil to a depth-of 3 feet: l 1ti �✓ w# Water table depth r SEPTIC TANK' g �— Capacity —� ...��' ❑_ Type/Mf �� _ Ca act No. Compartments / t - 1I PKG. TREATMENT PIT.. ;��'"1ii i r I rr I Method of Disposal 1 I Distance to nearest: Wel ` Foundation _ Property Line r F' LEACHING LITVE ❑_No. & Length of lines 1 ` I Total"IengZfi/size FILTER BED _qui Distance to nearest: Well Foundation Property Line,, � SEEPAGE PITO' w� DepthSize,' fi" Number . . SUMPS Distance to nei resi : •.-Wellm—"L Foundation Property Line DISPOSAL_P_ONDS__I___FL > __ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaglrin 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 certifies the following:;"I-certify thatin_the-performance of-the.work for which.this.permit.is-issued,-I.shall.empl'- persons subject to workman's compensa- tion laws of California" 1 The applicants I f all regfy i spections. Complete drawing on raver ide. Signed X _ Title: � Date: FOR DEPARTMENT�USE ONLY Y Application Accepted by ZIA Date Area Pit �Grou Inspection by Date �q Finat Inspection by �!//YC Datef o�/ b atJJ ']] r � `� Addition �omMel: Y1 - ❑ Stk 466-6781 ❑ Lodi -369-3621 V ❑ Manteca 823-004 ❑ fiacy 835-631 - Applicant- Return all copies to: 'Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box M, Stk. A 9, 01,kxa g�yc• �� r FEE INFO AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY DATE PERMIT N0. + EH13-24(REV. EH 1428