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Z APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT A A 11,601 E. H'AZELTON AVE., STOCKTON, CA } t p Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) I 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 Job Address 4' � ie�C /t'i�–'� City Lot Size�/ L � PM Owner's Name _ L� _? , z Address M244- PhoneAft i �7 Contractor Address License No. �� Phone `�"y'✓ i TYPE OF WELL/PUMP: EW WELL WELL REPLACEMENT © DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TAN SEWER LINES DISPOSAL FLD--' PROP. LINE --C-- j FOUNDATION _ AGRICULTURE WELL BOTHER WELL �~ PITS/SUMPS,/� INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 1.4 Dia. of Well Casing Domestic/Private Aaravel Pack ❑ Tracy Type of Casing Specifications CGf n j 1'1 Public ❑ OtF�er ❑ Delta Depth of Grout Seal gpDType of Grout I i Irrigation Approx. Depth I I Eastern Surface Seal Installed by ZZ _ Repair Work Done ❑ Type of-Pump _ {1, H.P. o60 State Work Done_ •Well Destruction ❑ Well Diameter Sealing Material (top 50') j Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is p\J r available within 200 feet.l v Installation will serve: Residence— Commercial_ Other a" ... Number of living units: Number of bedrooms i ' Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments; PKG. TREATMENT PLT. ❑ .'�r.� � Method`of Disposal Distancedo nearest: Well .Foundation 'Property Line^ 1 7. L [ ' LEACHING LINE ❑ No. & Length of lines w� Total length/size I "J FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS l I Depth Size Number t SUMPS 0 Distance to nearest: Well Foundation i Property Lino 4 r i 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." The applicant a requ, ( ions. Complete drawing on revs sr�de. Signed X Title: Date: / S R pEPARTMENT USE d LY C� / Application Accepted by Date r! Area r Pit or Grout Inspection by __- Ste/ ate f d Final Inspection by--.--, Date !b Additional Comments: / GI/L pid� i ❑ Stk 466-6781 ❑ Lod' 369-3621 ❑ Manteca 823-7104 ❑ Tr#6y 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201FEE 4 INFO AMOUNT CUE ' AM1.OUNZ REMITTED CAS . .'RECEIVED BY It DATE PppERMIT NO. ' ..EH 13-24(REV.t/H 5) rf lY� ---'�', j�� EH 14-2e 1'-