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t - APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT s 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 / .t ' PERMIT EXPIRES 1 YEAR FROM DATE ISSUED f ri` n (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, ��-7i /.� J' 1 Job Address —33el NN7�,®`IY c 1_40- G City Lot Size PM Owner's Name A R nia Lt tir'd Ea�&al Adc� dress 3-361 e_32& 71Plr 1101 1' Phone L?35 -6'10'- Contractor 09obContractor Address ._�A_ License No. PhoneX12 TYPE OF WELL/PUMP: _ NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ C�A` PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER Y jll0'4Fb4_ ?K*C- s DISTANCE TO NEAREST: SEPTIC TANK -SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS Z4 W, K INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ir4p -,-Ir--,-Ir- r pt p c l ❑ Industrial ❑ Open Bottom ❑ Manteca Dia- of Well Excavation Dia. of Well Casing `-M ❑ Domestic/Private ❑ Gravel Pack .❑ Tracy Type of Casing - -.__Specifications } f-I Public i=l Other { C] Delta Depth of Grout Seal Type of Grout I I Irrigation —.Approx. Depth I ] Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done_ { Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50 ' TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION (.l DESTRUCTION € I (No septic system permitted if public sewer is ' available within 200.feet.) Installation will serve: Residence Commercial_ Other Y 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. ompartmentsPKG. 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 f I Depth p Size Number SUMPS it 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 j 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: "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 pall for all required inspect ns. Co plete drawing on reverse side. r -Signed X� Title: .' -74 Date: 02 - r FOR DEPARTMENT USE ONLY i Application Accepted by Date f Area Pit or Grout Inspection by Date � ` Final Inspection by Date 33-P9 Additional Comments:� 4 -,evi, � l ElStk 466-6781 ❑ Lo 1 369-3621 Cl Mante 823-7104 Tracy 835-6385 r� ed�'! Applicant- Return all copies to: Envirorimental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box , tk., CA 95201 ! I n INFO FEE MOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO.. 1 r.Eli 13-24 1REV.I/H rl � / �� EH 1426 J (�/ v- y._-, -