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r� A APPLICATION FOR PERMIT ,�� rt SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUEDk Y (Complete in Triplicate) ,,'t.— 1, .* 0 f6 -* 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 forsewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. "-� i _.. . r�? t.., „gyp t;p Job AddressY� ✓w�/�QJ4rtG .City .�7Dfk;UA✓ Lot .'1Size PM 4 Owner's Name /GMP�✓/T��G'Lr�� Address,� ,/Il-fid/� � r G if Phone —Svc .2 �_ ontractor Address "^� License No. Phone_ TYPE OF WELL/PUMP: ZNEW WELL ❑ i Z WELL REPLACEMENT F1 DESTRUCTION ❑ PUMP INSTALLATION EIJ' + _JSYSTEM REPAIR ElOTHER ❑ s + DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP, LINE R FOUNDATION`�4AGRICULTURE 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 ❑ Domestic7Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public t ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by �. Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 t TYPE OF SEPTIC WORK: NEW INSTALLATION-❑ REPAIR/ADDITION ❑ DESTRUCTION Wo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence— Commercial_ Other Number of living units: Number of bedrooms t Y Character of soil to a depth of 3 feet: t .€ Water table depth SEPTIC TANK ❑ Type/Mfg s 1 Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance ton res . 1AffT_rvp1RLA FDroperty Line LEACHING LINE ❑ No. & Length o4mes9 aVex Ireld lAllhorgpl length/size' FILTER BED ❑ Distance to newark.rk �� "Property tine I huJ 9 SEEPAGE PITS ❑ Depth 5¢e i a Ir/I$Ili tuber SUMPS ❑ Distance to nearest: Well Foundation 'Property Line DISPOSAL PONDS ❑ 1 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 c111�1ertifies he-followirf—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 must call for all required inspections. Complete drawing on reverse side., k II— l' 7 Signed X -.,....--.-r---.k�Title:� � - .Date: --..� FOR DEPARTMENT USE ONLY Application Accepted by "C� , Date �� Area O � ! Permr Date � � e� Pas - Pit or Grout Inspection by Final In pection by Date Additional Comments: eS ❑ Stk 466-6781 ❑ Lodi 369-3621 C1 Manteca 823-7104 ❑ Tracy 8356385 q, 401� ( ; Applicant - Return all'coples to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 s FEE AMOUNT DUE AMOUNT REMITTED C K H RECEIVED BY DATE PERMIYNO. INFO (�7 + EH 13-241REV.1 95) ZI ZJ p kf— 17-C�7 O (-` • ! EH 14.26