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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL I ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED.. �..-n (Complete in Triplicate) 9 rtP �7 :FD�S'7—C.4k�.- r 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 ar No. 1862for well/pump and he Flrles and ulatians of the.$an Joaquin Local Health District.- ,(/ � d� .��/] r Job Address y i Lot Size PM z Owner's Name 7 .D� /oA�_I__1'VI.1?Q�d ��'��—IV,QIZ1 )4,Y'JJJ4��YA Phone b 9 l �t Contractor F ress _cense No. kr^ (tone 7 TYPE OF WELL/PUMP: F NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATIO SYSTEM RE�IR EI OTHER 13DISTANCE TO NEAREST: SEPTIC TANK �� r SEWER LINES /dD _ DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFIC TIONS ' ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 3�!M�f Dia. of 4ell Casing iW,Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other s ❑ Delta DepthYof 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 50') Depth Filler Material"(Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_; Commercial=' Other Number of living units: , ----Numberof bedrooms �r Character of soil to a depth of 3 feet: Water table depth k SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments I PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to neatest: Well Foundation Property Line f �.J• SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I 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 ot� employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub contracting signatur certifies the following:'-"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 �) tion laws of California." �✓ The applicaht rih t call far II req ' pecti s. Complete drawing on reverse 'de. ! Signed Title: ,� Date (/4' t 3 =FOR DEPARTMENT USE ONLY i' Application Accepted by Date Area Pit or Grout inspection by Date Final Inspection by Date Additional Comments: } ❑ Stk jl-].Lodi_ 369-3621 ___ ,0 Manteca 823-7104 _0 Tracy, 8:rfi _ I Applicant!- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.Q. Box 2009, Stk., CA 95201 FEE r - - I INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY �+ DATE PERMIT'NO. 1 + EH 13-241REV,1/e 5) -': O/� —�5 1 EH 14-28 *• c'7 , cis D / �b-qs