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APPLICATION FOR PERMITRECEIVED . SAN JOAQUIN LOCAL HEALTH-DISTRICT JUL 199.0 1601 E. HAZEL T ON AVE., .STOCKTON, CA Telephgrie"(2r ')'466-6781 ENVIRONMENTAL HEALTH; IPERMIT EXPIRES .1-YEAR FROM DATE ISSUED PERMIT/SERVICES (Complete n' Triplicate) % p 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 Sah Joaquin County Ordinance No.549 for sewage of Nd: 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. t i A fit Job Address City ` r CA&j Lot Size, PM Owner's Name 6181relofkf ddress Phone ` Contractor _PAddress ' ZZZ2�& N�6L44q License No.t /--�Phone f TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION ❑ _�� PUMP INSTALLATION ❑ SYSTEMH REPAIR t OTHER ❑ t s DISTANCE"Tb NEAREST SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE. FOUNDATION _ AGRICULTURE WELL ! OTHER WELL PITS/SUMPS i INTENDED_USE_ _ TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS € LJlndu ❑ strial ,Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing _%rbomestic/Private ❑ Graver Pack Q Tracy Type of Casing - Specifications iI Public ❑f Other t� ❑ Delta Depth of Grou�Seaj _ Type of Grout I I Irrigation t .Approx. Depth I I Eastern Surface Seal Installed.by ' Repair Work Done 0 Type of PumpI `53/lam H.P. State Work Done i Well Destruction ❑ Well Diametert e/ I Sealing Material trop 50').-" Depth Z Filler Material (Below 501 TYPE OF SEPTIC WORK: 'NEW INSTALLATION I ] REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is j available within 200 feet.) Installation will serve: Residence— Commercial— Other Number of living units: Number of bedrooms r � Character of soil to a depth of 3 feet: Waf_er_table-depth SEPTIC TANK ❑ Type/Mfg Gapacity� No. Compartments a� . PKG. TREATMENT PLT. ❑ Method of Disposal Q' »w a Distance to nearest: Well Foundation Property.Line t ; - LEACHING LINE'~ ❑ No. & Length of lines Total length/size "� 1 FILTER BED - ❑ Distance to nearest: k Well Foundation Property Lina SEEPAGE PITS" i I Depth Size SUMPS-s — Number Distance to nearesi: +rWe11�=-=-^- Foundationx Property-Line -�- - =-Rj. 4�� f DISPOSAL PONDS ❑ I hereby certify that I have.pre`pared 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'Cocal Health District. Homeowner-or-icensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I'shall no 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 Cali ia." �. The applic t call for all req r d inspect' ns. mplete drawing on raver side. Signed�X Title: ry _ f 1) Date: r! t Y FOR DEPAiRTMENT USE ONLY" Application Accepted by DateArea 1 ) Pit or Grout Inspection Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 635-6365 Applicant - Return all copies to: Environmefltal Health Permit/Services 1601 E. Hazelton Ave,, P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOU/NT�REMITTED CK 0 CASH RECEIVED BY' PATE PERMIT'NO, +.EH1 -241REY.1/851 ! r ��—�� „I EH 144-28 �/Y� r l7 l�Vj