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i APPLICATION FOR PERMIT ' SAN JOAQUIN LOCAL HEALTH DISTRICT NT 1601 E. HAZEiSC ON AVE., STOCKTON, CA IDIS ?"1 �tQ Telephone (209) 466-6781 VIPCA ��Ul PERMIT EXPIRES 1-YEAR FROM DATE I L (Complete in Triplicate) 1e1 S 1�6 Application is hateby 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. aIX)l dT Job Address --1._1f„900 '6/, Fi orit a� -P City h11215're ' ` Lot Size PM Owner's Name n r F fY�f:! P L"�+_ Address ` •^ r�i Phone co--d-t-0- Contractor i/�,;A Address 3 O C' t^: License No.Sl l 1#j. Phone 6 <31-1 1716� TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER 91 DISTANCE TO NEAREST. SEPTIC TANK /-�0_ SEWER LINES DISPOSAL FLO. PROP. LINE 0 FOUNDATION __ , AGRICULTURE WELL OTHER WELL PITSISUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial © Open Bottom Manteca pia. of Well Excavation 8:- ZDia. of Weil Casing =—A— rL ❑ Domestic/Private JW Gravel Pack ❑ Tracy Type of Casing-4-c-1- �0.d• r �.�' Specifications [71 Public 0 Other C'1 Delta Depth of Grout Seal _ 3 D _ Tyle of Grout 6 1 1 Irrigation SeApprox. Depth I I Eastern Surface Seal Installed by Repair Work Done 0 Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Seating Material (top 50') Depth Filler Material (Below 501) TYPE OF SEPTIC WORK. NEW INSTALLATION I I REPAIR/AODITfON i I DESTRUCTION I I (No septic system permitte7:1 available within 200 feet.) 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/MfgCapacity No. CompartmentsPKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE 0 No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS 0 Distance to nearest: Well Foundation Property Line DISPOSAL PONOS p 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 Or3[rict. 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 tion laws of California." is issued,1 shall employ persons subject to workman's compensa- The applicant must Call or all required inspections. Complete drawing on reverse side. SAN JOAQUIN LOCAL HEALTH DISTRICT igned , V!R MENTAL Hr-Al_��`�r� ; Title: Date: Y _ r 1000- FOR DEPARTMENT USE ONLY Application Accepted by Date IL" Area �P Pit or Grout Inspection by DateFinal Inspection by Date Additional Comments: ❑ Stk 466-b781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1501 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK a INFO RECEIVED BY CASH DATE PERMIT'NO. ..tik t�-2a1NEV.ti�s� � 84 taxa S- ®� i