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s APPLICATION FOR PERMIT1.� SAN JOAQUIN LOCAL HEALTH DISTRICT Pk � � fr y-b' z-Y w 1601 E. HAZEL T ON AVE., STOCKTON, CA 62� TelepP iOne (209) 466-6781 PERMIT EXPIRES 1 YEAWFROM DATE ISSUED *, (Complete in Triplicate) *. k 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 r d 8 '7-- Ci ma, Lot Size Ac�S?PM_ r L I Owner's Name �+ J�d Z�. Address o ata 4.� Q-9et-16e Q-- Phone 13rte' Contractor `d,JP�JLVAr, Address/"". icense No. 44�Phone � TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION PUMP INSTALLATION ❑ SYSTEM REPAIR ❑. OTHER E r DISTANCE TO NEAREST: SEPTIC TANK SEWER�LINES '� DIS_POS_AL FL—D"- rj `�PROP. LINE _ FOUNDATION AGRICULTURE WELL OTHER WELL J PITS/SUMPS _f INTENDED USE • TYPE OF WELL PROBLEM AREAS CONSTRUCTION SPECIFICATIONS LD Industrial ElOpen Bottom [IManteca Dia. of Well Excavation Dia. of Well Casing a1 ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications }l ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout �- ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by r Repair Work Done ❑ Type of Pump H.P. t . _ State WOtk,D66e i-- § Well Destruction ❑ Well Diameter ' Sealing Material Itop 501 O Depth Filler Material (Below 50') r TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) f Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal i Distance to nearest: Well Foundation Property Line , q LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest:- Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: . Well Foundation Property Line DISPOSAL PONDS ❑ t 4 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 shall employ persons subject to workman's compensa- tion laws of California." The applicant st call for all requi ed ins actions. Complete drawing on reverse side. Signed X Title: . _ Date: T O ' //r,� FOR DEPPVrMENT USE ONLY Application Accepted by Date '� Area /3 Pit or Grout Inspection by Date Final Inspection by Date h8� Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 IManteA 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Wealth Permit/Services 1601 E. Hazelton Ave., P.O. Box Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK# RECEIVED ay DATE PERMIT'NO. r INFO CASH a EH 13-24 IREV. EH 14-28