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APPLICATION FOR PERMIT r 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. 1861 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address20 f A 0 RO ft7�:> City F Lot Size PM i Owner's Name�+t&�'�,l Sk"y""�`��ddress " I -ED Phone Contractor's Name ' ' License No. V Phone r TYPE OFOtECC7PUMP:i NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ k-% } PUMP INSTALLATION 11 SYSTEM REPAIR 7-1 OTHER ❑ DISTANCE TO NEAREST:-SEPTIC�TANK '""�"""""'-"SEWER'L'INE-S /DISPOSAL FLD. PROP. LINE FOUNDATION UNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE !:)'—_TYPE q'FFWELL—.--.,PROBLEM AREA CONSTRUCTION SPECIFICATIONS y ❑ Industrial D Open $ottom r© Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private Gravel Pack ❑ Tracy Type of Casing Specifications 6-k j ❑ Public a O'Other '"-- - ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation - i _,�I_Approx. Depths� D��Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump Thr H.P. State Work Done` Well Destruction 01, Well Diameter -7 JSealing Material (top 50') DepthFiller Material (Below 50'} TYPE OF SEPTIC WORK: NEW INSTALLATIO 'U REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: i Residence Commercial— Other i i a Number of living units: Num ber-of.bedrooms-"` Character of soil to-a. depth of 3 feet: _ _ Water table depth SEPTIC TANK ❑ TypelMfg Capacity No. Compartments PKG. TREATMENT PLT ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED 1❑ Distance to nearest: Well Foundation Property Line F SEEPAGE PITS 1❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ ----1••hereby-certify-thatd•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.; 'j,;: ' f-j !`!- 1..4 :i � ,6-f `.f a Home owner or licensed agent's signature certifies the following: "1 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 ollowing:"I certify that in the peUns. Co e work for which this permit is issued,I shall employ persons subject to workman's compensa- tion laws o alifornia." The applic ust call fo a r red peo drawing on reverse side. ,^( Signed X Title: " Date: ,Z I'LAx N" FOR DEPARTMENT USE ONLY 1/► Application Accepted by Date(?- t! . "f Area_. Pit or Grout Inspection by Date Final Inspection by Rat Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 8366-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.D. Box 2009, Stk., CA 95201 FEE AMQUNT DUE AMOUNT REMITTED CK# RECEIVED BY DATE PERMIT"ND, INFO CASH I Yy +^EH 13.2a IREV.10/83) (.0—/9—)?7 /—�z7 . 6H 1426.