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APPLICATION FOR PERMIT f P SAN JOAQUIN LOCAL HEALTH DISTRICT i 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is heieby 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 welUpump and the Rules and Regulations of the San Joaquin Local Health District. III _ !! qq k Job Address r rr� f'h 4� V IVlcr+. k�CJ City Lot Size PM Owner's Name �eQ / Ge,2 5Ty (?/il SAddress Phone a- Contractor - !It Address P a hL �!-� l'Jcf:License No.-P-OM3-?�3 Phoneme 1 TYPE OF WELL/PUMP: NEW WELL)' WELL REPLACEMENT ❑ DESTRUCTION ❑ a PUMP INSTALLATION, SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD.L LPROP. LIVE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ! ❑ Industrial "Open Bottom ❑ Manteca Dia. of Well Excavation Dia, of Well Casing Domestic/Private L) Gravel Pack ElTracy Type of Casing e- L07P e"i- —�--- t`l Public FI Other } ❑ Delta Depth of Grout Seal , Tp r m lei Type Grout( e_ele. 1 1 Irrigation -Approx. Depth I.1 Eastern Surface Seal Installed by v4 Repair Work Done LJType of Pump r9 H.P- State Work pone _ { Well Destruction ❑ Well Diameter ,Sealing Material (top 501 DepthFiller,Material_tBelow-50')_---- :TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION IJ DESTRUCTION I I (No septic system permitted if public sewer is V! available within 200 feet) Installation-will-serve:- Residence_ Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: I Y - Water table depth ,SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT:❑,:: , ` ' _ti -- Method of Disposal i <. k Distan-ae'to nearest: Well foundation Property Line x z i f LEACHING-LINE ❑ 'No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth; Size -Y _ Number . .SUMPS k Cl Distance to nearest: Well Foundation Property Line 9 DISPOSAL PONDS .,0- 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_Di'strict._._ ,: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 not employ any person in such manner as to become subject to workman's compensation laws of California.'-Contractors hiring or sub-contracting signature certifies the following: '9 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 required inspections. Complete drawing on reverse sidle. } Signed .4 - A A.6A A Q Title: � O Y ,P S- "' Date: QR PART ENT USE ONLY p QQ { Application Accepted by * Rate �_.t"_._4 Area l Pit or Grout Inspection by Date7�� Final Inspection by_ 1 Additional-Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 D Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 20096;Stk., CA 95201 _ FEE MOUNT DUE }j AMOUNT REMITTED4A A4 L CASH CK RECEIVED BY DATE PERMIT NO. INF..EH 13-24(REV.i/nsl f i��`��, EH 14-26 f V V (J (+ J�