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F 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 k 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 1 Local Health District. y� Job Address v - `'�7 City Lot Size PM t Owner's Name ^' "" f�'4 Address /K/ Phone GAC � � 3 Contractor " !r/ Address �-Pst �- �_ �License No.�� /�Phone TYPE OF WELL/PUMP: NEW WELL C WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP'INSTACI:ATIOfq"❑'"'""""- SYSTEM-RfPA'IR-El, GTHER"-0-- DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FL.D, PROP. LINE 1 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS I INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial " ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 1"1 Public 171 Other CI Delta Depth of Grout Seal Type of Grout _ I I I Irrigation —.-Approx. Depth I I Eastern Surface Seal Installed by i Repair Work Done ❑ Type of Pump H,P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material (top 50') I Depth Filler Material (Below 50') ! } TYKE OF SEPTIC WORK: NEW INSTALLATION�-I:) REPAIR/ADDITION IC76DESTRUCTION l I (No septic system permitted if public sewer is # j available within 200 feet.) f < Installation will serve: Residence ✓ Comma"cial Other / u / Number of iliving units: _L_ Number edYoo;ms-Sh� Chf soil Character osoto a depth of 3 feet: u'r� � p ._� Water table depth SE�TICTANK LtYType/Mfg Capacity U No. Compartments PKGITREATMENT PLT. ❑ Method of isposal i , i Distance to nearest: W�?e 11 66 f Foundation &-2S Property.Line LEACHING LINE I C"o. & Lengt A of lines r' Total length/size Q FILTER BED I ❑ Distance to eares Well ` f Foundation 35 1 Property Line c t SEEPAGE PITS 14,1"-Depth f Size 1 Number 3 I H SUMPS 0 Distance to nIearestWeII 11L Foundation) a f Proper Line 70! DISPOSAL PONDS ❑ _ r t,� r r I hereby certify that I have prepared this application and that"the,w`�rlc will b i9onelnAccorda3nce with-San)J aquin county ordinances state taws, and rules and regulations of the San Joaquin Locaf-Health-D�trict. Home ownerr licensed agent's signature certifies the followin4'-�,-_t' -Atlhe�perfo mance of the work far which this permit is issued, I shall not employ any person in such manner as to became subject tol r arkinan'' pensahon laws of California."Contractor s hiring or sub-contracting signature certifies the following: "I certify that in the performance of he-�ork for wh�chYFiisipermit is issued, I shat)employ persons subject to workman's compensa- tion laws of California." I The applica us t call for II rebuired inspections. ,Complete drawing on reverge sidb�, Signed X ) t u.g1! Title: _ Date: tr �0 0 FORD PAR jiMENT USE ONLY Application Accepted by I Date Area /Pryor Grout Inspection by _/_J�� h� Date Final Inspection by ate " Additional Comments: ❑ Stk 4661781 ❑ Lodi 369-3621 ElManteca 823-7104 CO3acy (335 6365 I Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 (FEE AMOUNT DUE 1 AMOUNT REMITTED CASH I RECEIVED BY PATE PERMIT"ND. +.EH13-21(REV:1/95) 7V i EH 11-2e