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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON 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. - :;Lq06 Job Address 7699 NXffi EL EIML [b City .Sbcclrtm Lot Size PM Owner's Name _ARD. P10J1CtS Cb. Address P.O. 117w 5811 Sart M3tm, CA Phone — Contractor VQT 1M Ddl ir'm Address P.O. 1]13C 726zyjp30131, M License No. 376345 Phone TYPE OF WELL/ PUMP: NEW WELL N WELL REPLACEMENT ❑ DESTRUCTION ❑ �, ,�, J _, _ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER � Ny1 DISTANCE TO NEAREST: SEPTIC TANK J50 SEWER LINES <50 DISPOSAL FLD. IAF; PROP. LINE FOUNDATION <50 AGRICULTURE WELL 150 OTHER WELL M PITS/ SUMPS I� INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS d ❑ Industrial ❑ Open Bottom 0 Manteca Dia, of Well Excavation Dia. of Well Casing " A1 ❑ Domestic/ Private ❑ Gravel Pack ❑ Tracy Type of Casing M Specifications r"1 Public 7� � �C.�. X Other ❑ Delta Depth of Grout Seal '� Type of Grout I I Irrigation .�-Approx. Depth IX Eastern Surface Seal Installed by Chi 11 Pr _ Repair Work Done ❑ Type of Pump H . P. State Work Done �( I Well Destructi n ❑ Well Diameter Sealing Material (top 582) �� \ n1� - - 10 Depth Filler Material ( Below 50') TYPE OF SEPTIC WORK : NEW INSTALLATION I l 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 t 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 I I Depth Size Number SUMPS ❑ 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, 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. " Contractors hiring or sub-contracting signature certifies the following: "1 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 mut call for all reQwired inspections. Complete drawing on reverse side. Signed X G✓ b �i Title: PYOIECt Ce 1 Date: 5J r[ / OR DEPARTMENT USE ONLY Application Accepted by Date / Area / Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: 0 Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7169 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/ Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 9 INFO FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATEEi PERMIT' O s . EH 13-24 IBEy. rlxsl �� EH 13.28