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APPLICATION FOR PERMIT a SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209).466-6781 PERMIT EXPIRES I 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 Ryles and Regulations of the San Joaquin Local Health District. 4. Job Address Ci of Size PM Owner's Name / A9 If`/ -iAddress133 8 , F Phone Contractor Address /'IZ�S e^,Z7 License No./4623Z3 Phone ` TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION 0 _ L PUMP INSTALLATION ❑7 -SYSTEM REPAIR,21 OTHER ❑ DIST CE TO1,NEAREST: SEPTIC TANK /SEWER LINES DISPOSAL PLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Zdustrial El Open Bottom 7-1Mantecabia. of Well Excavation Dia. of Well Casing Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications A. Depth of Grout Seal Type of Grout C] Public C1 Other Ll Delia EJIrrigation pprox. Depth 11E st rn, Surface Seal Installed by Repair Work Done Type of Pump p 44- H.P.. } a� State Work Done Well Destruction ❑ Well Diameter 1 Sealing Material {top 501 Depth Filler`Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is r i available within 200 feet.) Installation will serve: Residence_ Commercial`•''!.,.Other Number of living units: Number of bedrooms I ' Character of soil to a depth of 3 feet: t. I Water table depth SEPTIC TANK ❑ Type/Mfg' `$ Capacity No. Compartments PKG. TREATMENT PLT. 1-11s Method of Disposal •Distance to-nearest- Well Foundation Property Line LEACHING LINE' ❑ Nor&.'Length of lines ( Total length/size a FILTER BED ❑ Distance-to nearest; Well Foundation Property Line i SEEPAGE PITST ❑ Depth _Size t Number I SUMPS Ll Diancestto nearest: Well Foundation Property Line r t DISPOSAL PONDS ❑ I ` I i hereby certify that I have prepatedd this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and i rules and regulation Sar_.Joaquin Local Health District. iHome owner o tensed agent ignature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any rson in such manner s to become subject to workman's compensation laws of California." Contractor's hiring or subcontracting signature certifies th following: "I certify that in the performance of the work f ich his permit is issued,I shall employ persons subject to workman's compensa- tion laws of California." The app icant must call all red ins ctio ing o reverse e. SOO V Signed Daie:I /Ari FOR DEPARTMENT USE ONLY Application Accepted by Date ��Q "` Area Pit or Grout Inspection by Date Final 4pectiori by�ffi Date Additional Comments: U(Stk 466-V81 O Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 8356385 w - Applicant' Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 1 i FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. - r 111 INFO CASH E + EH 13-24IREV.1/95I. AcC.. Q �s 111 EH 14-26 {