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APPLICATION FOR PERMIT Doi SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 -E..HAZE.LJOWAVE., STOCKTON, CA Telephone (209) 466_6781 A PERMIT EXPIRES 1 YEAR FROM DATE ISSUED is (Complete in Triplicate) Application is hereby made 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'"x"�'�- '6 �.W" l/l City Lot Size Owner's Name fAddress �.� Phone '� , Contractor Addr s License No., 76 Phone.4 AL-56L TYPE OF WELL/PUMP:— NEW-WELL El WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP,INSTi4LLATION ❑ `$�, ;,.AYSTjEM REPAIR OTHER El LI DISTANCE TO NEAREST: SEPTIC TANK SEWER NES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE- -TYPE-OS-WELL • PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ! ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing � t - ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public 1 ❑ Other ❑ Delta Depth of Grout Seal Type of Grout Cl Irrigation ---Approx. Depth CJ Eastern Surface Seal Installed,by ' Repair Work Done) Type of-Pump H.P. ___ 7?:, State Work Done K44 Ia-ce, tWell Destruction ❑ Well Diameter Sealing Material (top 50') ,-ru4�/ ,,,,":. Depth I Filler Material (Below 501 TYPE OF SEPTIC WORK:• NEW:INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is G' available within 200 feet.! Y_ t Installation will serve: ;Residence •: � Commercial_ Other Number-of living units:' Number of bedrooms 6. Char cter of soil to a depth of 3 feet: v Water table depth SEPTIC TANK ❑ Type'/Mfg` Capacity *`1--/ No. Compartments 1 PKG. TREATMENT PLT. ❑ � . Method of Disposal L Distance to nearest: Well Foundation Property Line } LEACHING LINE{ ❑ No. & L'eng'th of lines " Total length/sizej FILTER BED ❑ Distance to nearest: Well Foundation Property tine SEEPAGE PITS ❑ Depth Size �" Number SUMPS € ❑ Distance-to nearest: Well £Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that I hav this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulation the SanJo uin Local Health District. Home owner or I' ensed agent's sign tura certifies the following: "I certify t the performance of the work for which this permit is issued, I shall not { employ any pe n in such manner as a becoind'subject io ma 's pe" tion laws of lifornia:"Contractor's hiring or sub-contracting signature certifies the Ilowi g:"I certify that i t perfor anct3 of whit is p mit is d,I sha mploy persons subject to workman's compensa- tion laws o California." The appli nt mus r ad ins tion g on re rse fSigned Date: A4"I' R DEPARTMENT USE ONLY Application Accepted b Date - Area• 02- Pit 2Pit or Grout Inspectio y Date Final Inspection by -"bate Additional Comments: } ❑ Stk 466:6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385a Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.Q. Box 2009, Stk., CA 95201 FEE I 4 INFO AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY DATE FERMIT'':NO. +-EH 13-24 IREV.1/e 5) EH 10.28 �74 t , L -