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T APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZETON AVE., STOCKTON, CA Telephone {209) 466-6781 i PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) I' 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. F Job Address �4oS S�V�� C�S �eh�+�Q - City -S+0 t�pt Size PM IF b Owner's Name. y e-A F004—& 1_ZhC, Address W ®�� ^�,. Phone 14 6�1 � Contractor Re_QkAomd Address "£tu6�Q_K. &_)t- License No. Phone fb"--$534 .TYPE OF WELL/PUMP: z WELL El WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ NO�1br�Y► DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FILE). ROP. LINE FOUNDATION ,AGRICULTURE WELL OTHER WEL _ PITS/SUMPS {n INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS �► 11 LJIndustrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 110 Dia. of Well Casing ❑ Domestic/Private Gravel Pack- ❑ Tracy - Type of Casing tvz. Specifications FI Public Other ❑ Delta Depth of Grout Seal Type of Grout 1' I I Irrigation _--Approx. Depth I 1 Eastern Surface Seal Installed by A Rec.1r�P_f i Repair Work Done LI Type of Pump �� H.P. State Work Done _ { Weil Destruction ❑ Well Diameter"� Sealing Material (top 501 I MOw%A4z,r k1A Depth-- Filler Material (Below 501) TYPE OF SEPTI WORK: NEW INSTALLATION Ia REPAIR/ADDITION LI DESTRUCTION t I (No septic system permitted if public sewer is available within 200 feet.I Installation will serve: idents_ Commercial Other Number of living units: umber of bedrooms Character of soil to a depth of 3 feet: Water table depth k SEPTIC TANK ❑ Type/Mfg ' Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: We Foundation Property.Line TEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to'nearest: Well Founion Property Line i SEEPAGE PITS VI DepthSize Number SUMPS L] Distance to nearest: Well Foundation Property tine 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 f 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, (,;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 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 laws of California." The applicant must call for all r ired ins ctio Complete drawing on reverse side. - Signed X i Title: Date: OR DEPARTMENT USE ONLY Application Accepted by Date � N �� Area a" _ fe.ve. -SS&--- --7 , Pit or Grout inspection by Date Final Inspection byW 1b Date �-� Additional Comments: ❑ Stk 466-6781 1 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Appficant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 fFEE AMOUNT DUE I AMOUNT REMITTED 0 RECEIVED BY DATE. PEHMIT"NO. Yl (%gr SN +.EH13-24 1rtEV.i i n 51 t EHT4-28 ✓✓ ,,.