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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466_6781 f 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. 1662 for well/pump and Local Health District. 1 the Rules and Regulations of the San Joaquin Job Address City-44`Jr Lot Size C PM Owner's Name Address �n -sczsAi mbA4 Ami Phone Q Contractor v r Address i7.C_, 4 � •';Nfimmse No..+2S43.4_ > YPE OF WELL/PUMP: ,NEW WELL C7 - T 3,Phone_ a .4 WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION Q SYSTEM REPAIR ❑ --.- , _ `,A''t DISTANCE TO NEAREST: SEPTIC TANK r OTHEFE:171 A I- SEWER LINES - DISPOSAL FLD. `PROP. LINE o FOUNDATION AGRICULTURE WELL OTHER WELL IPITS/SUMPS t 'V INTENDED USE TYPE OF WELD PROBLEM AREA CONSTRUCTION SPECIFICATIONS r W l9clustrial ❑ Open Bottom ❑ Manteca - k ❑;Domestic/Private Dia. of Well Excavation! ' Dia. of Well Casing r ❑ Gravel It ❑ Trac ,.; Y Type of Casing � �k �0 ❑ Other S1 cifiications ! 11 Public ❑hbelta Depth of Grout Seal t Y ' 71\ ❑ Irrigation �Approx, Depth ❑,Eastern Type of Grout } Repa;Work"Done ❑ Type of Pump H P Surface Seal Installed by I State Work Done= A Well Destruction ❑ Well Diameter f Sealing Material (top 50') I Depth I iFiller Material (Below 501 I TYPE OF SEPTIC WORK: NEW INSTALLATION ❑` REPAIR/ADDITION ■ DESTRUCTION INo"t I system permitted if public sewer is t 0 available within 200 feet.I Installation will serve: Residence Commercial Other Number of living units:_L Number of bedrooms Character of soil to a depth of 3 feeta d + SEPTIC�TANK • Type/Mfg ;OI�GfJI:.i_E , '20 -table depth. PKG. .TREATMENT PLT. ❑ ' Capacity fAl. No. Compartments f' t` f Method of Disposal r Distance to nearest: Well 1 Oil - Foundation_( d r , . � ► Property Line LEACHING LINE ❑ No. & Leri th of lines �T�M ► g fS NTotal length/size ! 1 FILTER.BED ❑ Distance to nearest: Well Foundation t"Property Line r SEEPAGE PITS ❑ Depth SizeJV[ SUMPS,. Number ❑ Distance fo nearest Welr �% r'1YFoundtion # DISPOSAL PONDS ❑ 4# Property Line 1 I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin coon rules and regulations of the San Joaquin Local Health District. , j q county rdinances, state laws, and 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.compensation4aws of.ealifomia."Contractor's hiring r sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issuedI shall employ tion law's of California." o- p , p y persons subject to workman's compensa- tion applicant must call for all required inspections. Complete drawing on reverse side. f Signed _ Title: Date: 1-:3k)"3E�ris'J FOR DEPARTMENT USE ONLY Application Accepted by Dater 1 Pit or Grout Inspection by l Date Final Inspection byj # Date � Additional Comments: Stk 466-6781 ;❑ Lodi 369-3621 ❑ Manteca 823 7104 ❑.Tracy 835 6395 plican{- Return all copies to: Environmental Health"Permit/Services 1601 E. Hazelton Ave., P.O.-Box 2009, Stk., CA 95201 1� 1NF0 AMOUNT DUE I AMOUNT REMITTED CK CASH RECEIVED BY DATE PERMIT'NO. (�] 03 ! + EH 13-24(REV,i n i 5) EH 14-28