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F APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT � 1601 E. HAZE T ON AVE., STOCKTON, CA I Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR'FROM DATE ISSUED A< (Completein Triplicate) !s. 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 Ryles and Regulations of the San Joaquin Local'Health District. sI. �l 7 So pec �� .�.. I . " �r. .. Job Address 1 (,�J' n- rtiity yrF Lot Size `GG `G PM w Owner's Name �' m !d Ic% Address �( -717 5• V .. l�/'o J, ! 1 QI?*a Phone Contractor Lcyz 1 dress m.e License No. 037 Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ t`f' SYSTEM REPAIR ❑ OTHER ❑ - DISTANCE TO NEAREST: SEPTIC TANK ' SEWER LINES DISPOSAL FLD. PROP. LINE, VA FOUNDATION AGRICULTURE WELL OTHER WELL • --PITS7SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS F-1 Industrial ❑ Open Bottom ❑ Manteca. Dia. of Well Excavation '+ Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Trac f T ` '_ Y J ype,of Casingr Specifications O3 ❑ Public ❑ Other i ❑ Delta De th:of'Grout Seal `M P -Type of Grout-- . . . .... ❑ Irrigation —Approx. Depth ❑ Eastern Surface Seal Installed by ' e. Repair Work Done ❑ Type of Pump, H.P. `. State Work Done ,]c. ;Iy.,.r. Well Destruction C] Well Diameteri . ..a Sealing Material {top 50') r Depth �-Filler MaterialF(Below 541 'TYPE OF SEPTIC WORK: NEW INSTALLATION ❑. REPAIR/ADDITION DESTRUCTION ❑ iNo septic system permitted ifublic sewer is 'f rA � available within 200 feet.) P Installation will serve: ,ResidenceXI Commercial 1Other Number of living units:J_ Number of bedroom ,_ a Character of soil to a depth of 3 feet: t �0 Water table depthAW-MAY SEPTIC TANK Type/Mfg r R Capacity__ No. Compartments PKG. TREATMENT PLT. ❑ r S Method of Disosal Distance to nearest: Well f U0 Foundation �� Property Line>-k&— LEACHING LINE No. & Length of lines 0b.�-. JrTotal length/size n FILTER,BED ❑ Distance to nearest: Well ,}4[� Foundation 2! _ Property Line = t ' -- ""`""SEEPAGE-PITS- + ❑-wDepth •'�-' Size Number . SUMPS ❑ Distance to nearest: Well - ,Foundation Property Line A DISPOSAL PONDS ❑" 3' 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 r'rules and regulations.of the San Joaquin Local Health District. *Home oWnet or licensed agent's signature certifies-the following:"I certifythat in the performance of the work for which this permit is issued, I shall not i certifies the following employ any person g such manner as to become subject to workman's cdrnpensation laws of California."Contractor's hiring or sub-contracting signature tion laws of California.";" s compensa- ' : "I-certify that in the performance'of the work for which this permit is issued, I shall employ�- oy prsons subject to workmanf The applicant must call for all required inspections7 Complete drawing on reverse side. (I�^�J p I ( Title: t. r -- �w� � asl�C(.0 Y ��n / r f Lod PART U 1VLY � �-{�t�{' Application Accepted by Date Area Pit or Grout Inspection by N .Date Final:Inspection by Date i Additional Comments: � ��'� IQ - � i wY��-► a ❑ Stk 466-6781 ❑ i 369-3621 anteca 823-71 ❑ Tracy 83 '; -Applicant Return all copies to: Environmental Hea Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 aiu FEE AMOUNT DUE AMOUNT REMITTED' INFO -CASH RECEIVED BY 4 DATE .. PERMIT"NO. 00 _..+EH 13-24 EH 14-26IREV.l/651 .— 0& IWC L/ -i VG fIJ1.IFrf �� 6� gb�b