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s .�F APPLICATION-FOR PERMIT k } SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE.,-.STOCKTON, CA Telephone (209) 466-67$1 I PERMIT EXPIRES 1 YEAR FROM DATE ISSUED M 4 (Complete in Triplicate) i' 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- F Job Address Sado _F City tftdkOP. Lot Size T S /IGI'eS PM Owner's Name Address �r�0 c//S� Phone 209 5o l ContractorL�OffeG r Address y163ly CArISAY Street- License No. 1V611/3a4/Phone S i TYPE OF WELL/PUMP: _ { —',.NEW WELL ❑ WELL REPLACEMENT ElDESTRUCTION El ; PUMP INSTALLATION ❑ 1 SYSTEM REPAIR ❑ OTHERX?n0A/17`nR/nIG C00-4L DISTANCE TO NEAREST: SEPTIC TANK -SEWER LINES 200 DISPOSAL FLD. M114 PROP. LINE FOUNDATION Z SF AGRICULTURE WELL _!1251 OTHER WELL PITSISUMPS.,oM&.- },* 'e INTENDED USE;- TYPE OF.'WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ,t ❑ Open Bottom' ❑ Manteca 'Dia- of Well Excavation IF /07 r- Dia. of Well Casing' 2 ❑ Domestic/PrivateGravel Pack° ❑ Tracy Type of Casing leva Specifications .z { ❑ Public ❑ Other ❑ Delta ¢ Depth oft#OWSeal 3 Fee—IL Type of Grou'tNefftC k srtn"N• If�G ED Irrigation .- " � ❑ e pprox. Depth Eastern Surface ea nstak ed by Repair Work bane ❑ Type of Pump H.P. State Work,Done { Well Destruction ❑ Well Diameter � 11? Sealing Material !top 50'1 r ` ti) Depth 2:6 f eP_-t` Filler Material {Below 50 ; { 'J-3^' TYPE OF SEPTIC WORK: NEW INSTAL TION ❑ REPAIR/ADDITION ❑ ESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet! { `Installation will serve: Residence_ Co ercial_ Other 1 ( Number of living units. Number of bed- ms r Character of soil'to a depth of 3 feet: Water table depth i SEPTIC TANK ❑T Type/Mfg Capacity No. Compartments PKG._TREATMENT=PLT. ❑ F # Method of Disposal Distance to nearest: Wel Foundation Property Line 4 LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well oundation Property Line I SEEPAGE PITS ' ❑ Depth Size Number ..f SUMPS ❑ Distance to eorest: Well Foundation -Property Line DISPOSAL PONDS ❑ ' 1. 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 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 applican must call for all required 1 cti s. plate drawing on reverse side. SQL Rt}t;!��` ✓ANG p fff Signed X Title: Date: /a 7 FOR DEPARTMENT USE ONLY Application Acca y Date J 7 — 7 Area Pit or Grout Inspection by Date Z/_ Final Inspection by Date 7 � a Additional Comments: i ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 I Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 k FEET INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY PATE PERMIT ND. + EH 13-24 IREV.i/H 51 ; O f �'7—1--0 EH 14-26 1_