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�a r ,s =; APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT PAYMENT l� 1601 E. HAZE.T ON AVE., STOCKTON, CA df W Telephone (209) 466-6781 r 13910 PERMIT EXPIRES 1 YEAR FROM DATE ISSUE© p ��A JOAQ!}11 IN j':SJr.iI��Tti' (Complete in Triplicate) �c�: Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install tlois'JitlYff �hir8c�hiil}t �ljon 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. =; ra Job Address �� 4(V`(Jh City C1 4", Lot Size PM Owner's Name Address 'U V A41CO3 41, Phone z^336 t r I "l!ZContraclar Q License No.�� dZ� , r � M 1. TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLA ON ❑ SYSTEy REPAIR ❑ OTHER 17 DISTANCE TO NEAREST::SEPTIC.TANKK-e— �,SEWER,LINES- 114,014�e- ,DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL l� OTHER WELL�I& PITS/SUMPS j INTENDED USE r�T�YPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIOf1S f ❑ Industrial �.Ltpen Bottom ❑ Manteca Dia- of Well Excavation Dia. of Well Casing Z6 ❑ Domestic/Private ❑ Gravel Pactk ❑ Tracy Type of Casing �1 ee 'C Specifications v❑ 'Public ❑ Othe��s�1 ��,51J-� Delta Depth of Grout Seal r� Type of Grouts P _ y�trri{lation Aprox., ept�t7 I ] Eastern Surface Seal Installed by ►" Repair Work Done ❑ Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material (top 50'1 Depth Filler Material (Below 501 T TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is # available within 200 feet.) Installation will serve: Residence k 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 Distance to nearest: Well Foundation Property Line I LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED L1 Distance to nearest: Well Foundation Property Line SEEPAGE PITS i I `Depth I Size _ Number -- F SUMPS— -� Ul.- Gistance•to-nearest:T.n--Well-� -------=Foundation -- � Property-L-ine"----�� .. -� - ,=_=ter DISPOSAL PONDS ❑ 11 Y 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 shall employ persons subject to workman's compensa- tion laws of California." The applicant must ca31ll1 for �all /required inspections. Complete drawing on reverse side. ? q Signed X_1�l t✓ xyd 4?�l[rf � Title:N t6le, > FOR EPARTMENT USE ONLY ( Application Accepted by Date, Q Area - Pit or Gr ut spection by Date p Final Inspection by Date Additional Comments: ❑ Stk 466-6781 Cl Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE r INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. :a K r.EH 13-24(REV.i/K5) 7=; 4'��L ��J C4 ,�S L s EH 14-2MI