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Y � d APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT ' 1601 E. HAZELTON AVE., STOCKTON, CA - a Telephone (209) 466-6781 t 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. I i Joh Address `f t7�J�i 1V e-Lo! rc.7 City t� �ibt Sizes PM Owner's Name fA_)fL-L? /A& �/ilr7�s+� Address i4OL2 e-Wi hri Q� Phone 71577] Contractor's Name � o6�'e�- License No. � � Phone �' r TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy - Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by .Q Repair Work Done ❑ Type of Pump H.P. State Work Done _ } Weil Destruction ❑ Well Diameter Sealing Material (top 50'1 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION J* REPAIR/ADDITION ❑ DESTRUCTION ❑ 1No septic system permitted if public sewer- is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other rUt1C�� Keepm * = Number of living units: __QL_ Number of bedrooms s ' Character of sail to a depth of 3 feet:_E+1-t-, - Water table depth b- t SEPTIC TAMC ❑ Type/Mfg C ty�L No. Compartments �Y�C�..S i Capacil�� PKG. TREATMENT PLT. ❑ r Method of Disposal Distance to nearest: Well Foundation__.L� Property Line LEACHING LINE Uj No. & Length of lines 6VIe �8 r _ Total length/size 40 FILTER BED ❑ Distance to nearest: Well 15Q Foundation,Qd Property Line /a ' SEEPAGE PITS Depth o�.� ' Size r Number a+`1 e— SUMPS ❑ Distance to nearest: Well Foundation Property Line .� 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 District. 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 Califomia." The applicant must call for all ed ' pectiona. Complete drawing on reverse side. Signed -JlJLQ_ t0 A Title: Date: FOR DEPARTMENT USE ON f� 'Application Accepted by `o' a to Area J� Pit or,Grout inspection by Date Final Inspection by Data Additional Comments: ;6.1 ❑ Stk 466-6781 ❑ Y.0i 369-3621 ❑ Manteca 823-7104 �❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH CK 0 RECEIVED BY DATE �}PERMIT`N0. + EH 13428 24 IREV.101831 EH 1 4/5✓ #&/o V III