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t - r APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 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. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address �Q ! ,c —. City t Lot Size G rM Owner's Name _�J Q�,,:�1�J`'P !!�L'A drL r/ — Phonej Contractor Address License No.a-f q R ,�Phone 7 7 } TYPE OF WELL/PUMP: WELL WELL REPLACEMENT D RUCTIONS a t I I- - PUMP INSTALLATION a SYSTEM'REPAIR_R r OTHER,0- DISTANCE TO NEAREST: SEPTIC TANK �_.Q' SEWER--LINES-w - DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PETS/SUMPS INTENDED USE TYPE OF.WELL PROBLEM AREA CONSTRLICTION--SPECIFICATIONS--- :` ❑ Industrial Open Bottom ❑ Manteca t Dia. of Well Excavation Dia. of Well Casing .Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications I'1 Public El Other �• { ❑ Defta Depth of Grout Seal Type of Grou x I f Irrigation QAf) pprox. Depth l I Eastern C :, Surface Seal,Installed bycA Repair Work Done ❑ Type of Pump H.P. - ` State Work Done Well Destruction ❑ Weil Diameter Sealing Material (top 50') Depth It Filler;Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION 1:1 REPAIR/ADpITION I 1 DESTRUCTION .l I (No septic system permitted if.public'sewer is �u t ! 4 r- available within 200 feet.) l Installation will serve: -Re§idence�=r. Commercial_ Other fyNumber of living units: i Number of bedrooms t t Character of soil to a depth of 3 feet: '��"`� •' - ., Water table depth SEPTIC TANK ❑ Type/MigOpacity - PKG. TREATMENT PLT. FIt e^.. No. Compartments r Method of Disposal ' Distance to nearest: Well Foundation Property Line ;4 r � LEACHING LINE ❑ No. & Length of lines Total length/site l�- FILTER BED ❑ Distance to nearest: Well Foundation Property Line #I _ SEEPAGE PITSr I ] Depth :I Size ' SUMPS Number _ n Ll Distance to nearest: Well Foundation Property Line ; Vl DISPOSAL PONDS ❑ i 4 I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordin rules and regulations of the San Joaquin Local Health District- ances, state laws, and , Home owner or licensed agent's signature certifies the following: "i certify that in the r i employ an f1r performance of the'work for which this permit is issued, I shall not P y y person in such manner as to become subject to workman's compensation laws of California,"-Contractor's hiring or sub-contracting signature *i.f. 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." F The applicantm 11 t call for all required,inspections.'Complete drawing on reverse slid a Signed X Title: e_1 ` Date: + FOR DEPARTMENT USE ONLY Application Accepted by Date �/` +f -Cz l� +�1� y�, Area " Pit or Grout Inspection by Date L__P: Final Inspection by Ak r Date 6 Additional Comments: �. I D Stk 466-6781 ❑ Loi 369-3621 Ma eca 82�7 �TI �vFLjr-638 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 ..<..-..r-�,..-� -FEE ---._�._� _- LL� _ -----_ •- -- - - - -� _ _ __ INFO AMOUNT DUE ' AMOUNT REMITTED CK FRECEIVED BY CASH DATE PERMIT'NO. *SEH 13-24(REV.tir5EFI 14-26 1 - . - to /