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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE.,-STOCKTON, CA Telephone {209} 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED • r �� 'r {Complete in Triplicate}- : .t" _ y 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. r i Job Address CityK< Lot Size PM Owner's Name �` Address O s Phone s Contractor 4! J-trGg:: -Address ®c License Nom ts"z!�Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT W ` DESTRUCTION ❑ I PUMP INSTALLATION ❑. - SYSTEM REPAIR E! OTHER 111i DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE i rFOUNDATiONW —AGRICULTURE WELL W OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 1 r Ll-industrial t, ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 7 ❑'Domestic/Private ❑ Gravel Pack ❑ TracyType of Casing Specifications V ❑ OtherT7 Delta Depth of Grout Seal Type of Grout ❑ irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by E ; Repair Work Done ❑ A,TypeLof Pump H,P. State Work Done Air Well Destruction E7 Well Diameter Sealing Material flop 501 Depth Filler Material (Below 50') T 'PE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION.❑ DESTRUCTION ❑ (Nb septic system permitted if public sewer is t �''^. -•�•�-- �. is-�- .._v �+ -� -- - -.�,/c . ...:-. , ^�__.' available WRhin.200 feet.) Ihstallation will serve: Residence CommercialL! Other l � r Number of living units: "F ;I" Number of bedrooms ; Character of soil to a-depth of 3 feet: :54wpy Water table depth SEPTIC TANK �T r ype/Mfg Capacity No. Compartments 2- ( 3 PKG. TREATMENT PLT, ❑ r, �.�-^ Method of Disposal r Distance to nearest: Wel( ' •� Foiindafion`s t Property Line LEACHING LINE ❑ No. & Length of lines Total length/size r { FILTE6EDR i Oanceonearest: Well FoundationProperty y Liner Q� I � E SEEPAGE PITS ❑ Depth Size Number 1 } 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 accordancewith San Joaquin county ordinances, state laws, and i rules and regulations of the San Joaquin Local Health District, 3 Y ! ..•Horne oinrner 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 sihiring or sub,contracting signature r 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'scompensa- tion laws of California." i Thapplicant-must call-for- ll-requiredlnspections"Compl t{drawing on reverse srde ( Sidned ) �' e Title: Date: t { orf � FOR DEPARTMENT USE ONLY Application Accepted by r .s `` -� ' '� Date } ' , `� Area 3 # Pirpr Grout Inspection by Date Final Inspection- y 'w - Date t Additional Comments: vim 'T r - �a - ❑ Stfc r 466-6781 ❑ Lodi 389-3621 anteca 823 710rEx"3 ` ❑Tra Vt 835-63$5,'4 j Applicant:- Return all copies to:-Environmental Health Permit/Services 1601E Hazelton Ave:, P.t7.iBox 2009, StkCA 95201FEE , "INFO AMOUNT..�PUE.-,;_a-„„„-AMOUNT-REMITTED �CK RECEIVED 8Y` �� f CASH DATE.-..- -PERMIT + EH 13-24(REV,I/B 51