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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA I Telephone (209) 466-6781 ' PERMIT EXPIRES 1 YEAR FROM DATE ISSUED f (Complete in Triplicate) a IC Application is hereby made to the San Joaquin Local HealthDistrict 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 Sh-',.� �h7��t.v Job Address i ty N A& f� 6: �P_T14 V City c_ Lot Size PM Owner's Name A, Address �4 r>9�- Phone y 'Ji4 a Contractor L rE Prith Address 524;Z behpn1My License No4aIS"3d Phone 0 46`-O I TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION LISYSTEM REPAIR ❑ OTHERXM�� DISTANCE TO NEAREST: SEPTIC-TANK ®�� ;SEWER LINES e4OpO t� DISPOSAL FLD. PROP. LINE FOUNDATION --Z40—' AGRICULTURE WELt �QOf "OTHER WELL !6 PITS/SUMPS AI P E INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 2 AIt ElIndustrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation ,� Dia. of Well Casing lr ❑ Domestic/Private %4V Gravel Pack Tracy Type of Casing Specifications r ❑ Public ❑ Other ❑ Delta Depth of Grout Seal � Type of Grout e ►97 ►x 4 v - ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by �- Repair Work Done ❑ Type of Pump, H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (Nb septic system permi 'public sewer is available within Installation wi e: Residence_ Commercial_ Other Number of living units. Number of bedrooms Character of soil to a depth o t: Water table depth r SEPTIC TANK ❑ Type/Mfg Capac' No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: We Foundation Property Line LEACHING LINE ❑ No. & Length s Total length/size FILTER BED ❑ Dista o nearest: Well Foundation Property Line s SEEPAGE PITS ❑ Depth I Size Number i _ SUMP —❑ Distance to nearest: Well Foundation Property Line OSAL PONDS ❑ Q 1 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. r 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 f 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 alifornis." k The applicant m t call for all eq trod in pections. Complete drawing oonn,�reverse side. -Signed L Title: ,, 1`� Date: �'Z C. FOR DEPARTMENT USE ONLY Application Accepted by Date 47 Area Pit or Grout Inspection by ate _7457-97Final Inspection by JV/A Date r T. r Additional Comments: r S G re�/1 "F' =r h-1 4P, 'f ❑ Stk 466-6781 ❑ Lodi 369-S621 ❑ Manteca 823-7104 ❑ Tracy 835-63135 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CKJV H RECEIVED BY DATE PERMIT`NO. INFO + EH 13.24(REV.i/e 5: EH 14-25