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x - APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT r 1601 E. HAZEL—ION 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 Rules and Regulations of the San Joaquin Local Health District. 42G Job Address G $ �d City Lot Size - PM f Owner's Name 2-Au L `-a 196 - ,Address Phone Contractor t b[ , �f cY Address 1�` License No.aPjjs��Phone E TYPE OF-'WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION Q SYSTEM REPAIR ❑ OTHER ❑ _DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE �1 V FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS f INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS f°Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ' ❑'Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications i El Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout r00Irrigation --Approx. Depth 11 Eastern Surface Seal Installed by :r' Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material Itop 501 Depth Filler Material(Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Res di3nce', Commercial Other M- oNumber of living units:L_ Number of bedrooms ha Cracter`of soil to a de th'of 3 feet:"° `f` `Lc„ �" " p Water table depth SEC'TIC TANK LJType/Mfg PZIE j Capacity No. Compartments ► PKG. TREATMENT PLT. ❑ F^ Method of.Disposal j Distance to nearest: Well l� Foundation c Property Line " LEACHING LINE No. & Length of lines * �'�7�/ t � r Total length/size f FILTER`BED S Q Distance rnearest: —Well��-F-6 rid_ation. F� Property Line � f SEEPAGE hTS� l ❑ Depth 00 PT- Size �d � �D Number tSUMP9 """. Distance to nearest: Well 16!6 Foundation 00 )=7 PropertV-Line—l--`•---- DI8POSAL PONDS ❑ I hereby certify thatTKave prepared this-appiicationland thafthe work will-be done in accotdance with San"Jo_agUiri,aourat>yr ordinances, state laws, and rules and regulations of the'SanLJoaqum Local Health-District-a .• ' �` r 4 0 k' 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 io workman's compensation iavws of California."Contractor's hiring or sub contracting signature certifies the following: "1 certify that in the performance of the work for which thia permit is issued;/.shall employ persons subject to workman's compensa- tion laws of California." § � The applicant must call for 1 rd inspections. Complete drawing on reverse side. e ' Signed X a _ Title: Date: A DEPARTMENT,USE ONLY F rz Application Aoceptod Eby, t�. r" Dates Area t Pit or Grout Inspection by Date, Final Inspection by Date .f' Additional"Comments- El Stk 466-6781 ❑ Lodi 369-3621 .. ❑ Manteca 823-7104 ❑ Tracy 835-63M I Applicant Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE.-—AKi6UNT DUE AMOUNT REMITTED' '•CASH RECEIVED BY DATE PERMIT`NO. 5 n + EH 13.24(REV.1/a 5) S`, EH 1428 � 7�'Z3 r