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t 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 Distract 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. ?� 4 t 070-�t Job AddressaP 7)61 �7GZA�L��1 - City Lot Size PM I Owner's Name 0ZrA%1W 'YL�lT�t7�W� Address O If f}Z Phone ��M--3 SrLx?f Contractor vHira r5 I R /rcc? __Address 7 -i504AF b 6E License No. Phone to q S=t TYPE OF WELLIPUMP: NEW WELL El WELL REPLACEMENT C DESTRUCTION PUMP INSTALLATION 71 SYSTEM REPAIR ❑ OTHER G } I DISTANCE TO NEAREST: SEPTIC TANKSEWER LINES DISPOSAL FLD. PROP. LINE k FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ i INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS �y L" tndustrial ❑ Open 9ottom L] Manteca Dia. of Well Excavation RA r Vpi�MENT Domestic IPrivate ❑ Gravel Pack El Tracy Type of Casing FO Pubfic I-.? Other r 1 Delta Depth of Grout SealAta t� liTr &,u 'Q _ Irndauon _ Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done 0 Type of Pump H,P. State Work D o.'-VICES Weil Destruction ❑ Wel! Diameter`- 'p `.*. `'Sealing Material (top 50'I ��RnW (fit r{CI DI1fl51�i1 4 Depth —Filler-Material-(Below-50')— I YPt 50'1''"TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDIT_ION f i DESTRUCTION Mo septic system permitted if public sewer is I w + ,) • I`'� Installation will serve: Residence_ Commercial !,Other— - ` available within 200 feet ; t Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: !j It Water table depth .D b SEPTIC TANK ❑ Type/Mfg PKG. TREATMENT PLT. Q Capacity . G®� Er No. Compartments 9A _ Method of Disposal Distance to nearest: Well A lam : Foundation Property Line =—SO lP1 - LEACHING LINE 0 No. & Length of linesI � Total length/size A_ I FILTER BED ❑ Distance to nearest-. Well Foundation - Property Line , i I SEEPAGE PITS I 1 Depth Size Number SUMPS LI Distance to nearest: Well Foundation DISPOSAL PONDS F1Property Line�+ f ! 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 fotlowing: "I Certify that in the performance of the work for which this permits issued, I shall nor .i employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or subcontracting 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 comprfnsa- tion laws of California." The applican us call or ll required inspections. Complete drawing on reverse side. •�� Signed X �. Ut `t �` -� L Title: �0� °a Date: FOR pEPARTMENT USE ONLY Application Accepted by Datel— Area Pit or Grout Inspection by Date Final Inspection by Date Aj Additional Comments: r ❑ Stk 466-6781 ❑ Lodi 369.3621 ❑ Manteca 823.7104 ❑ Tracy 835-6385 r Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 952o1 r FEE AMOUNT DUE AMOUNT REMITTED INFO C RECEIVED BY DATE PERMIT NO. E1J-ZI SREV. EMH 1.24 + S. �,� �17C1� / g1_0g2,1 1U� �J(! k