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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRIG1 1601 E. HAZELTON AVE. , STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 ' YEAR FROM DATE ISSUED (Complete in Triplicate) Application is heiehy 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. Job Address aOs o ca.+.t- F,,�e.vr� �,nsl- st City SftrD kiy^ Lot Size PM Owner's Name T'SYl "A&e U' �uS-Et�c. Address 5CA3� phon4ca) kiV4 s3slm M Contractor Ca'Yt Address 1140 Vt.f'VION $j" RuBVIILYGerise No,2 S5YG Phon TYPE OF WELL/ PUMP: NEW WELL �( .SHELL REPLACEMENT ❑ DESTRUCTION ❑ i PUMP INSTALLATION i SYS�TEMR�PyAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES V._17_ DISPOSAL FLD. PROP, LINE FOUNDATION AGRICULTUflE WELL U OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS fl ❑ Indm fralhbv%;JOC ❑ Open Bottom - ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private '6( Gravel Pack/5"A ❑ Tracy Type of Casing 5(.k 40 PVA Specifications I') Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout _. _ 1 I Irrigation < (C O '�.Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H , P, State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501) Depth Filler Material ( Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I1 REPAIR /ADDITION I I DESTRUCTION I I ( No septic system permitted if public sewer is 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: Water table depth SEPTIC TANK ❑ 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 1 . FILTER BED ❑ Distance to nearest: Well Foundation Property Line 00 SEEPAGE PITS I I Depth Size Number SUMPS Ll 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, an rules and regulations of the San Joaquin Local Health Dil;trict. . Home owner or licensed agent's signature certifies the following: "1 certify that in the performance of the work for which this permit is issued, I shall no 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 laws of California." The applicant all r u//r/��} ins ons. Complete drawing on reverse side. Signed X. = K=J� Title: _ /"/'iS i [�✓nl Date: FMPA fT USE ONLY Application Accepted by Date A a Pit or Grout Inspection by,� / Date d Final Inspection by Data'1.a Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7166 ❑ Tracy 835-6385 Applicant - Return a0 copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED-TED ETED CASH aa RECEIVED BY DATE PERMIT' NO, EH 1IaEV. I / H51 S , �O EH 13 4-M Za