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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON 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 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. 93a :t, Job Address 11 &0 p4 '`' +' V I t Tt7 ( 1�-�7 _� l�OC[.'� City Lot Size PM Owner's Name Address 116 a"R QeSi 6 Phone Contractor d S o Address S /e License No. Phone TYPE OF WELL/PUMP: NEW WELL 1� _ WELL REPLACEMENT ❑ DESTRUCTION ❑ ylY � PUMP INSTALLATION ID Lae - ,,,,#,r�t SYSTEM REPAIR❑. '� OTHER 5� rM��r�w5 !t/ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE " FOUNDATION' AGRICULTURE WELL OTHER WELL PITS/SUMPS r INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS !, ❑ Industrial ❑ Open Bottom ❑ Manteca. Dia. of Well Excavation _ Dia. of Well Casing 1-1 Domestic/Private El Gravel Pack 4 ❑ Tracy Type of Casing ysf PVL Specifications ❑ Public' til w *�- ® OtherSAAO s Ll Delta Depth of Grout Seal 35 _ Type of Grout Coy,Cw-k- ❑ Irrigation 41e Approxi_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')-F--- - - —�- --- Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ ,REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is i available within 200 feet.) Installation will serve: Residence� Commercial Other Y R 0 ?f g Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC,TANK Q Type/Mfg Capacity No. Compartments 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 nearest: Well Foundation" Property Line SEEPAGE PITS ❑ Depth Size f4°` Number SUMPS ❑ Distance to nearest: Well ` `° Foundation Property Linef M R 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 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 call for ins t' ns. Complete drawing on reverse side. Signed Title: S.S �r i � !.� Date: a g A ae�Dg-ye D A ME E ONLYApplication Accepted by Date Pit or Grout Inspect n A--.&'9 f Ihspection ate $�� Additional Comments: 3 d 5 h 4 Dur I� Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 5-6385 Applicant- Return all copies to:Xnvironmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 I FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT-NO. EH 13-24{REV.t/esl r EH 14-26 � �• �