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.0 1 APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.-HAZELTON AVE-, STOCKTON, CA Telephone {209} 466-6781 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. Job Address City ESG� - Lot Size - r 1t.�9& i PM A n � -0 Owner's Name 1-4ay S?AO - Address 6 ne f Contractor F Address Qr License No. 246 913 Phone",s TYPE.OF WELL/PUMP:. NEW WELL,)k WELL REPLACEMENT C1DESTRUCTION ❑ PUMP INSTALLATION LJ REPAIR ❑ ' - OTHER C1 DISTANCE TO NEAREST: SEPTIC TANK J lbPe. SEWER LINES DISPOSALF.FLD.�� PROP.:)LINE _ FOUNDATION" - - -AGRICULTURE WELL. OTHER.W,ELLPITS/SUMPS INTENDED USE TYPE OF,WELL PROBLEM AREA CONSTRUCTION" PECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia- of Well Casing X Domestic/Private Gravel Pack ❑ Tracy Type of Casing � -019ve, Specifications [7 Public ❑ Other ❑ Delta Depth of Grout Sear-._�540'0 1 Typ9 of Gr I I Irrigation --Approx. Depth I 1 Eastern Surface Seal Installed by Repair Work:Done ❑ Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter/ r .t. ,Sealing Material stop 501 Depth Filler Material (Below 501 -- PE OF SEPTIC WORK: NEW INSTALLATION la REPAIR/ADDITION I I DESTRUCTION { I (No septic system permitted if public sewer is _. R - _- r " _ r.. ., available within 200 feet.) Installation rve: Residence— :Commercial_ Other Number of living units: Nu"mbe7�of~bedrooms Character of soil to a depth of"3 feet: Water table depth SEPTIC TANK *❑ Type/Mfg r 'Capacity fijo."Compartments PKG. TREATMENT-PLT. ❑ Method of Disposal Distance-to-nearest:- `-Well"-- - - -Foundation Property Line 44. LEACHING LINE ❑ No. & Length of-lines �" "' t�` Total length/size } FILTER BED' 11 Distance to nearest:-, Well Foundation Property Line SEEPAGE PITS 1`1 Depth Si29 Number SUMPS LI Distance to Nearest:"' -z Well t --- aundation r Property Line y Y ,DISPOSAL PONDS ❑ - - - — Wlaws, and. " - i_heaeby=certify that f-have-prepared=tiis��plica�i875 arid'that"the`work'wi11 be done in`accordance"with San Joaquin county ofdinances;state rules and regulations of the San Joaquin Local Health District. - Home owner or licensed agent's signature certifies the following:;.I ceitify'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 followi "1 certify that in the performance of-the work for.Which'this permit is issued,-1 shall employ persons subject to workman's compensa- tion laws o 'Caiifoy.__-.- The appli t m call for.all require spections. omplate drawing r arse de. - } !r ' Signed K - -•Till -- Date: ` y FOR �TMENT USE ONL Application Accepted by Date 7 Area /4 i Pit or Grout Inspection t�/ _ Date Final Inspection by Date yr y Additional Comments; - - - - -- ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 f Applicant -Raturn all copies to: Environmental Health Permit/Services 1601..E. Hazelton Ave.,.-P-.O. Box 2009, Stk., CA 95201 _ FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BYDATE PERMIT"NO. INFO CASH a EH 13.24(REV.I/x 51 �'—�- EH t4-2e