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APPLICATION FOR'PERMIT ° SAN JOAQUIN LOCAL HEALTH DISTRICT 4601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6181 f PERMIT EXPIRES 1 YEAR FROM DATE ISSUED , f (Complete in Triplicate) Application is hereby made tot he San Joaqquin Local Health District for a permit to construct and/or install the work herein described. This application uis made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations o t e q Local Health District. �. f ,maS c 0C)Z O / 1 1 f City O' N Lot Size PM Job Address .} ��/ l�T�l Address Owner's.Name-1K0—a_,, i7C O License No. �v 0 Phone CY77 Contractor's Name jc)h�d, — { TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ s PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER°❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. ~ PROP. LINE 4 FOUNDATION .i AGRICULTURE.WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well•Casing ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Specifications \i ❑Domestic/Private ❑ Gravel Pack Y D Tracy Type of Casing Type of Grout ❑ Public El Other '� E3 Delta Depth of Grout Seal D Ifrigation ---Approx. Depth'-ElEastern Surface Seal Installed by 'I Repair Work Dorie ❑ Type of Pump H.P. State Work Done y QS Well Destruction ❑ Well Diameter Sealing Material {top 50'I \\ # Depth Filler Material (Below 50') 1 r f1 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION.4 : DESTRUCTION ❑ aNailablelwithine200 feet'tjed if public sewer is w , Installation will §erne: Resideiice� Commercial*� Other Number,of IiVing units:'r. Number of Bedrooms yWater table depth Character of:soil to,a.depth of 3 feet:) r `SEPTIC TANK t Q Type/Mfg {_r Capacity No. Compartments Method of Disposal qKG. TREATMENT.PLT.'-O • ( I f ' Property Line t j( .r Distance to nearest Well Foundation 5 - LEACHING-LINE f No. &,Length of lines Total Iengthlsize , FILTER BED ElDistance 'to nearest:' Well Foundation Property Line SEEPAGE PITS Depth 72Siie Number—,ii— ,,1, SUMPS ❑ Distance to nearest: Well—5 Foundation L[�'T Property Line DISPOSAL PONDS ❑ I hereby certify that's-have-prepared•this-appticatioh-ahid`titaCtth�'work will be done in accordance with San Joaquin county ordinances, state laws, and. rules and regulations of the San Joaquin Local Health District. } -is;�4 permit is issued, I shag not Home owner or licensed agent's signature certifies t6e'following: I certify that in the performance of the work for which tFi employ any person in such manner as to become sdbject to workman's compensation laws of California."Contractor's h ring or sub-contracting signature certifies the following:"1 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 California. -~ The applicant mus c for all'required�inspections. Complete thawing on reverse side. Title: Date: Signed FOR DEPA ENT USE ONLY00� } �7 2r E Area t. cation Accepted by Date ;r Date Final Inspection by Date ''�� DPICGrout Inspection by T�y r, ttlonal-.Comments:---- -- Stk -466-6781--,l,co n ` C7 Lodi 369 3621 — �-❑ Manteca 623-7104- .� ❑ Tracy 835 6385 .- -Applicant•--Return all-copies-to:-Environmentai-Health=Permit/.Ser ices-1601-E: Hazelton-Ave•�P:OrBox-2009;Stk:;CA 95201 FEE CK RECEIVED BY DATE INFO PERMWNO. �- AMOUNT DUE AMOUNT REMITTED CASH +EH 13-24 IREV.10183) AI!5-7 19 EH 14-26