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APPLICATION FOR PERMIT a SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZETON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) } Ja(3 J�fOr ��—Z/yp—D3 Application is hereby made to the Sa J..qC7Local/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. /VC�Z._Oc�Q_I��C7 � jejSTift/J L�F� �I 2 Job Address WC }i�lr}l»�Y) T 1 /J�� aIF� wy_ I 1 City _57-y-4%) Lot Size PM Owner's Name S L! Address 90ZS- C�M - Phone AfZ7 Contracto M �NF�t tress__- S77<4-j License No, ' Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER % c7 "Of,4 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. . BAF--E+NE �� f FOUNDATION AGRICULTURE WELLZS OTHER WELL � ow INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation n a „f WPII c2sm.,. ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing S.peei4ieatie ; D Y F] Public ❑ Other ❑ Delta Depth of Grout Seal Tyrpe-ef-6 t HOL466 «' I I Irrigation --Approx. Depth I 1 Eastern Surface Seal Installed by _� ��l- I 0 Repair Work Done ❑ Type of Pump H.P. State Work Done_ pL.I[,f,W IF- Cos V Well Destruction ❑ Well Diameter Sealing Material (top 50') I Depth Filler Material (Below 50') _ TYPE OF SEPTIC WORK: NEW INSTALLATION f] REPAIR/ADDITION l I DESTRUCTION I 1 (No septic system permitted if public sewer is ; available within 200 feet.) Installation will serve: Residence— Commercial— Other a Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth N SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal JA Distance to nearest: Well Foundation Property Line K r. LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I 1 Depth Size Number I SUMPS C Distance to nearest: Well Foundation Property Line r DISPOSAL PONDS ❑ 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 Di§trict. 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." i The applicant nriLksit call for all r4auired inspections. Complete drawing on reverse side. Signed X� Q _ Title: CiJ Date: 46 OR DEPARTMENT USE ONLY I Application Accepted by OYW04Date 46�_.16 _ Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: Qa9� ' i. ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 623-7104 ❑ Tracy 835-6385 49 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 . t FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT*NO. ♦.EH 18-24(REV.I/x 5) EH 14-29 5.22 �1 0 90-1570t