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it APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 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 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 Address6�r1 ` �C/��T/`! City � � Lot Size f� X I PM Owner's Name DU 05 Ate-- ILL Address 156-171 Phone Contractor sell—/` Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC'TANK SEWER LINES DISPOSAL FLD. PROP. LINE A FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS W ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications CA ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by 0 Repair Work Done ❑ Type of Pump H.P. State Work Donee Well Destruction ❑ Well Diameter Sealing Material (top 501 !SP1!!r!i Depth Filler Material iBelow 501 OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installation wi Residence_ Commercial Other Number of living units: Number of bedrooms Character of soil to a depth of 3 fee . Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well dation Property Line LEACHING LINE ❑ No. & Length of lines ..° ngth/size ` FILTER BED ❑ Distance to nearest: Well Foundation Prop ine SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation 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 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 manner as to become subject to workman's compensation laws of California." 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 shail emptoy persons subject to workman's compensa- tion laws of California." The applican u t call for all required insp ions. Complete drawing on reverse side. ( Signed X �' _ r �) Title: __ eQ Date: I -7 FOR DEPARTMENT US ONLY Application Accepted by Date Z-Z7 LAreat-15�Pit or Grout Inspection by -Date Final Inspection by __P1 Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi3621 ❑ Manteca 823-7104 ❑ Trac 835-6385 - -�� Applicant- Return all copies to: nvironmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH/ RECEIVED BY DATE tPEERMITT,NO. + EH 13-24(REV.t"15) /._c_� 3 S 04� `lam." / /�/7,f// y-1 -63 EH 14-28 6J ?00 I / / 0 p IJ 6