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f v� r--t f APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone 1209? 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 wado in compliance witlr San Joaquin County Ordinance No. FA9 for sowage or No. 1862 for well/pump and tire Rulus and Regulations of the San Joaquin Local Health District. Job Address CJe� - -S City r►\t Lot Size PM r r`S / `f l ash .7 ltir"1 a� Owner's Nanro ._.._..___�._..... .- I �'J Address __�_._.___—._— Phoma _ I ei6j ,l6 s"i�yst Zoo Sz 7 2�7/ Cnnhactnr..U�, (�' 1�j_(G�_-fi7h Atfdress �-36y/e. /�Oy� License No. �r� Phone TYPE OF WELL/PUMP: NEW WELL I l WELL REPLACEMENT I"1 DESTRUCTION 1.1 PUMP INSTALLATION L1 seg rw, SYSTEM REPAIR Ll OTHER �C��.vr,/a,� fir•K�1 DISTANCE TO NEAREST: SEPTIC TANK W+ 6 SEWER�INES _ DISPOSAL FLD. 4F_._. PROP. LINE FOUNDATION y0� AGRICULTURE WELL� OTHER WELL��Odr PITS/SUMPS_ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I1 Industrials rY I.1 Open Boltorn IJ Manteca Dia. ofAO06ff Excavation_ 6" Dia. of Well Casing � - (1 Domestic/Private I:.1 Gravel Pack I-1 Tracy Type of Casing_ /U�� _ Specifications I'l Public W01her � 11 Delta Depth of Grout Seal ZO =i�— Type of GroutCcm� I I Irti{tatian 0'Approx. De )Ih I 1 Eastorn Surlace Seal Installed by Pe . Repair Work Done i 1 Type of Pump -- - _.._.--.--... H.P. ----------------.-----.—�- State Work Done rr Well Destnrction f I Well Diameter Sealing Material (top 501 Depth ____zO.r Filler Material (B©low 501 TYPE OF SEPTIC WORK: NEW INSTAI LATION I I REPAIR/ADDI[ION I I DESTRUCTION I I INo septic system permitted if public sewer is available within 200 fact.) Installation will serve: Residnnro Commercial Other Number of Elvin{f units: ..._.-_.. Numhrr of bedrooms -------`-f-T-`- Y`_ /fJU/ Charactrr of soil to a depth of 3 Irrt: _____..-_ Water table depth / SEF''fIC TANK I I Type/Mfg .._ .... -- _____W Ca{>acity.___._.__�_._— No. Compartments PKG. IREAIMFNT PI.T. I I Method of Disposal . O Distance to neares(: Well _ ._ Foundation__ Propeny Line LEACHING LINE i I No, & Length of lines _ _ _ ---__- Total - /� FILTER RED I I Distance to noatost: Well Foundalion _ Property Line SEEPAGE PITS I I Depth __.._..._.Size - Number SUMPS I I Distance to nearest: Well_ Foundation -- Property Line �T DISPOSAL PONDS t l I hereby certify that I have prepared this application and that the work will be clone 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 mariner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature cerlifies the following: "I certify that in the performance of the work for which this permit is issued, t shall employ persons subject to workman's compensa- tion laws of California." The applicantmust for all required inspecti plate drawing on reverse side. Signed X %�/• Title: rtlU`re.rs.rG•,rft.[ �ioi �1-,�rs�r.;—Date: FOR DEPARTMENT USE ONLY Application Accepted by _-_ Date `3 Aro. Pit or Grout Inspection by C Date C� Final Inspection b Date Additional Comments: I 1 Sik 466 6781 C] Lodi 369 3621 Cl Manteca 823-7104 1-1 Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CKrIyII RECEIVED BY DATE PPEE�RMII7'NO. . EM!]-a1 Info.rind a. 0d Cl .