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i APPLICATION FOR PERMIT -` SAN JOAQUIN LOCAL'HEALTH DISTRICT 1601 E. HAZEL T ON+AVE, STOCKTON, CA ` Telephone {209} 466-678l PERMIT EXPIRES 7°YEAR'FROM DATE ISSUED (Complete in Triplicate} �.. � r . •:=' aa�1s t .'.• : ,i: .,. 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. -;q»%i4 , , Job Address 'v^t' . ' fi'� t w.�qC . City Lot Size ' � � •. ..iY' .� as � K� is. � k;' : If.s:= ' ' tEE,_.y�-. PM Owner's Name' Address I — Phone - Contractor 4.-4s /�'aLG _ Address r� �T�`�License fVa. TYPE OF WELL/PUMP: NEW WELL ❑* Phone _ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMA INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES1 DISPOSAL FLD, PROP. LINE FOUNDATION AGRICULTURE ELL OTHER WELL PIT, SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS � i _ Industrial If Open Bottom ❑ Manteca Dia. of Well Excavation ! i ❑ Domestic/Private C1Gravel Pack El Tracy T _ Dia. of Well Casing• ❑ Public Type of Casing Specifications ❑ Other ❑ Delta Depth of Grout Seal F] Irrigation Type of Grout --Approx. ❑ Eastern Surface Seal Installed by a Repair Work Done ❑ Type of Pump H P J State Work Done Well Destruction ❑ Well Diameter. Sealing Material (top 50') . Depth 1 ' � Filler Material {Belo'w 50.'} TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION LJ {No septic system permitted if public sewer is - °��^ -«ti- available within 200 feet.) F V'installation will serve: Residence�t Commercial_. Other i Number of living units:__-I-- Number of bedroorr s Character of sail to a depth of 3 feet: SEPTIC TANKWater table depth ❑ Type/Mfg i I ! ; PKG. TREATMENT PLT. ❑ { Capacity� �� No. Compartments 1 Method of Disposal z ' Distance to nearest: Well Foundation Property Line j LEACHING LINEi No. & Length of lines l (x(j F 7 Total length/sizei FILTER BED r ❑ Distance to nearest: Well Foundation 41.1 ff — Property Line N.- SEEPAGE PITS = ❑ Depth _, .r -_�. .'Side t. — 4 SUMPS `Number' ❑ Distance to nearest: Well t;. Foundation DISPOSAL PONDS ❑ Property Line '- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state la rules and regulations of the San Joaquin.Local'Health.District. ws, and 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." _ x r ty The applicant must call for al requirecL inspections.!Complete drawing on reverse side. Signed Xa //— ;�� Title.- Da te: . FOR DEPARTMENT USE ONLY t F Application Accepted by Vj4 i Date Area Pit or Grout Inspection by Date Final Inspection by Additional Comments: Date � El Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 ; Applicant- Return all copies to. Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk„ CA 95201 FEE AMDUNT DUE..::m .:..�AMOUNT...REMITTED_._._CK# fNFO� CASH---- .RECEIVED BY__- _- -DATt PERMIT'NO.' f EH 13-24(REV. d -•.F •i y�� ,p.�_.- ... _..-1.w-.- �,• _ i EH 14-28 ';-.�" .. - .. _ ...,.,�11y-/z.. -,-�,, 4 7-30 Ca.? -+-