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Il _ i� II APPLICATION FOR PERMIT �! SAN JOAQUIN LOCAL HEALTH DISTRICT �l 1601 E. HAZE T ON AVE., STOCKTON, CA li Telephone (209) 466-6781 �I PERMIT EXPIRES 1 YEAR FROM DATE ISSUED l �t IComplete 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. " Job Address 0� ��'� City ,1C�.4 Lot Size PM � � 'II, Owner's Name w✓J Address Phone u Contractor Pero -3� Pl�l aS* � L .s0 �a A TYPE OF WELL/PUMP: it NEW WELL ❑ 'WELL REPLACEMENT ❑ 1 DESTRUCTION ❑ PUMP INSTALLATION ❑ _ _ SYSTEM REPAIR ❑ OTHER ❑ _ DISTANCE TO NEAREST: SEPTIC TANK + SEWER LINESDISPOSAL FLD. PROP, LINE { FOUNDATIQN 'AGRICULTURE WELLER WELL PITS/SUMPS fi INTENDED USE TYPE OF WELL PROBLEM ARE _A, UCTIOM`SPECIFICATIONS ❑ Industrial %` 1 .0 Open Bottom ❑ Manta _;., .Dia`of Well Excavation Dia. of Well Casing f - ❑ Domestic/Private ❑.Gravel Pack racy Type of Casing Specifications [ i Public ❑ Other f 1.Delta-,„__Depth of Grout Seal . Type of Grout; I i Irrigation pprox. Depth I i Eastern Surface Seal Installed by _ Repair Work Done Type of Pump H.P. 1 t "# .'' t State Work Done_ Well Destru ❑ Well Diameter Sealing Material (top 50') 'i t ii Depth Fillet Materiail f Bel'w 501 TYPE OF, WORK: NEW INSTALLATION I`1 -REPAIR/ADDITION DESTRUCTION I ),.INo septic system permitted it public sewer is 1r !. available within 200 feet-) Installation-will -.serve: R idence ---.Commercial_: Other Number of living un " Number of bedroomsG" .+ + Character of soil to a depth of 3 feet:, Si�/y r ��C�LK� Water table depth SEPTIC TANK ❑ Type/Mfg ` Capacity No. Compartments l �' PKG. TREATMENT PLT. ❑ il. S 1 "' Method of Disposal Distance to nearest: Well Foundation Property Line it I 1 LEACHING LINE No: & Length of lines Total length/size FILTER BED _ . ❑ Dx Distance to nearest: Well Foundation- Property Line l SEEPAGE'PITS^'*�-, :,'r 1,1 Deptli Number SUMPS 1�,4 kNkistance to nearest: Well Foundation - Property Line DISPOSAL PONDS ❑ I hereby certify that.I have,prepaiecl 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 licenser(agent's slignature certifies-the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any,person i cIn manndr as to.bkcime'_subject-to workrpan_s"compensation laws of California." Contractor's hiring or sub-contracting signature certifi8s the followi I certify tFifet in the performance of the work for wh'icfithis-permit is-issued;' -employ-persons subject to workman's compensa- tion laws of Calif ni ." a 'f The applican . all+far I requir spections'. o e dravvirig on rev rsd 'side.. �- ;i Signed X ; Title: Date: / '^ FOR-DEP RTMENT-l1SE•ONLY.v._...�-.. .�•�:.-�_.-,.,.,�- . --....-...- .,_ -,.,., r .�,... Ap cation Accepted b Date ` Area ti it o out I�pe on b ate ~l Fi I Inspection by Date -� Ad itional Corrfinents. 0 '❑ Stk 466-6781 ❑ Lodi 36gr3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Avd., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH CK 9 1-—/RECEIVED BY DATE PERMIT NO. 19a VV +.EH13-24IREV.1 fly) EH 14-28 !! I{ i�