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1 APPLICATION FOR PERMIT SAN JOAQUIN 'LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA i Telephone (209) 466-6781- PERMIT 66-6781PERMIT EXPIRES 1 YEAR FROM DATE ISSUED i (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 Ryles and Regulations of the San Joaquin Local Health District. C� ' Job Address 03 CK f D'' T/V�� n T rte' City 5-for_ �Ly q Lot Size PM 1 =Owner's Name SUCLQbl/X C�IJ/r� "Address /AZO STaGJ rIAo— Phone r v3—z 71) /� �} '[�!f_ tl,,� i/`tea yap fo�/� [� / j_ Contractor LoYDL�1A WQ+'e11_ 'mac �f Address #C40 P� L4 �nU1lY.i 4 License No. Phone /l5 f�7I z* TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ i PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES 50%ef DISPOSAL FLD.' PROP. LINE � FOUNDATION 1 rJ AGRICULTURE WELL OTHER WELL�� /��PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS `!` 46 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Domestic/Private ,Gravel Pack ❑ Tracy Type of Casing F VC, Specifications O�� ❑ Public ❑ Other ❑ Delta Depth of Grout Seal /D 16�. MdnL, TYPe�°f Grout E3Irrigation ,��pprox. Depth ❑ Eastern Surface Seal Installed by ,f O L Repair Work Done ❑ Type of Pump H.P. State Work Done \ Well Destruction C7 Well Diameter Sealing Material (top 501 \ g Depth Filler Material IBelow 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (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 FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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 must call for all required in pe ions. omplete drawing on reverse side. Signed X_ Title: Date: O EPARTMENT USE ONLY Application Accepted by Date 'le` Area Pit or Grout Inspection Date Final Inspection by Date ,/ ,-s Additional Comments u/zV 19�Stk 466-6781 ❑ Codi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P. . Bo0' x 2009, Stk., CA 95201 FEE• INFO AMOUNT DUE AMOUNT REMITTED ASH cgg RECEIVED BY DATE PERMIT'NO. �-» H s +EH EH 1428 13-24 IREV.5/a 5Y 3..7 0 - •Li L/O l