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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZETON AVE., STOCKTON, CA Telephone (200) 466-6781. - , PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ;l (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. Job Address 74, �0 ►r" Y " ` City DL' 7Lot Size PM Owner's Name E�l ' Address Phone 02 1� '14,? S I4 -3 Contractor 06P /4 A Address 1 a Q 7<.C�6�C License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTI PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHE ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRU&ION.SPECIFICATIONS�. ❑ industrial rip•1 Open Bottom ❑ Manteca Dia. of Well Exaa Aion �" Dia. of Well Casing I� ❑ Domestic/Private ,`-'�❑ Gravel Pack ❑ Tracy Type of Casing Specifications E ❑ Public ❑'Other Cl Delta u Depth of Grout Seal Type of Grout El Irrigation K 'j �� __Approx. Dept , 1 �❑ as ern Surface Seal Installed by Repair Work Done" ❑ Type of Pump ,U/Q 1Y�H.P. State Wor Done D R g Sealing Material (top 50') C C- T Well Destruction Well Diameterr�. _ I Depth_ G` ' Filler Material (Below 501 /C 41ec�L,1' F TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is „ .•' available within 200 feet.) t Installation will serve: Residence Commercial,.,,_..Qthec. � t i Number of living units: Nur. roof bedrooms I 3 [ Character of-soil to a depth'of 3 feet: Water table depth V� SEPTIC TANK ❑ Type''/Mfd r CapacityF No. Compartments i PKG. TREATMENT PLT. LIL ey 'ki 1 Method of Disposal < Distance to nearest: Well Foundation Property Line $ LEACHING LINE ❑ No. & Length of�lines: length/size .�v , a..tii•Foundation Property Line.r *• FILTER BED.- ❑ ' Distance to nearest: Wella SEEPAGE PIT ; ❑ ,:Depth's Size Number r: i f SUMPS ❑ "Distance to nearest:V1/ell�Fou`nation Property Line DISPOSAL PONDS ❑ I 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 f rules and regu)ationslof 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 id such-manner-as-to become subject to workman's-compensation-laws-of-Califomia..-Contractor's�hiring-or-sub--contracting signature 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 Ca' rnia.” The applicant st call f r all req ' d inspectio s. Complete drawing ot1 r erse e. / t .Signed Title: O/V '� 9 e-TO Date: f OR DEPARTMENT USE ONLY rI Application Accepted byIL Date r(� Area Pit or Grout Inspection by ate Final Inspection by Date f Additional Comments: L1 Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy { Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 I ' FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT''NO. INFO + EH 18.24(REV.1/85) EH 1425