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APPLICATION.FOR PERMIT %4 x SAN JOAQUIN LOCAL,HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED in,�Tri (Complete P P�licate) 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 �-� /1'l XPAW Z-1 City STK Lot Size 967)0&0 PM Owner's"Name ib CGLA J�� A36c& Address - �� Phone Contractor F4& Y" E GtdOVb .Address 6d,5�:ifl, d-14-41AA1 A1071_icense No_j��Phone+�GX= y/ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ 1 PUMP INSTALLATION ❑- '"�""` "� °'SYSTEM'"REPAIR"'❑ OTHER-171— DISTANCE THER-171 "'"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 CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑,Tracy Type of Casing Specifications (� ❑ Public 0 Other ❑pelta Depth of Grout Seal Type of Grout I l ❑ Irrigation L__Approx. Depth ❑:Eastern Surface Seal Installed by Repair Work Done L1 Type of Pump " H.P. State Work Done T I t Well Destruction ❑ Well Diameter" Sealing Material{top 501 Depth I Filler Material [Below 501 I j TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is available within 200 feet) I 3� Installation will serve: Residence Commercial OtherW�tR f Number of living units:" Number of bedrooms e E Character of soil to a depth of 3 feet Water table depth tea.- SEPTIC TANK Type/Mfg Capacity —No.-Compartments � PKG. TREATMENT PLT. ❑ j } ' Method of Disposal Distance to nearest: well . Foundation 'Property Line # LEACHING LINE ❑"No. & Length of lines `t Total length/size x � J FILTER BED l .❑ Distance to nearest: Weil Foundati n y ' a Propertyine SEEPAGE PITS 4 ❑' Depth M i (Size Number'.— l SUMPS. Q Distance to nearest: : Well Foundation Property Line ` r DISPOSAL PONDS ❑ :1 { 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, I 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." t• The applicant must call for all required ins ti s. Complete drawing on reverse side. Signed �r/ Title: N{t P, .4' [rl Date: FOR DEPARTMENT USE ONLY Application Accepted by Date , �� Area Pit or Grout Inspection by _ Date Final Inspection by Date t r / Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ,, ❑ Manteca 823- ❑ Tracy 835 Applicant- Return"all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA'95201 FEE n1k AMOUNT DUE r� AMOUNT REMITTED CK H -RECEIVED BY' DATE PERMIT N0. + EH 13-24(REV.1/551 1-1'.,�U i.... �a. �Cj"L� ---"'-'-.- {.i'1 I kin EH 14-26 F ✓ (�J �J i