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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 1 (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 Ordi ance No.55499 for ssaawawgeoor yyo. f or I urnd the Rules and ullap',onsk q�f Jtha S Joaquin1 Local Health District. r// Q ayppp,,I (JL+rI+ 'W 4 >�yr•' �a �f�l��c �� Job Address !), �rVV .Yt�L1 City lot Size IL1 PM/ Owner's Name r.. -r'wZ. Address Phone S-5 aU v Contractor(_JL lZ� Addressla 81z dX / �L:5�'O t� License Net Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ �UMPJNSTALLATION.❑„ , SYSTEM REPAIR ❑, . „ OTHER-El— 1 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. =i PROP'L1NE FOUNDATION •^ AGRICULTURE WELL OTHER WELL__ ELL 1 PITS/SUMPS INTENDED USE TYPE OF WELLA:• PROBLEM AREA CONSTRUCTION SPECIFICATIONS ' ❑ Industrial C Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑-Gravel Pack .,,,,��❑,Tracy,,, Type-of.Casing ---- Specifications M Public ❑ Other F.I.Delta Depth of Grout Seal Type of Grout_. I I Irrigation Approx. Depth- ( I.£estern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump -- H.P:. State Work Done _ Well Destruction . _0 Well Diameter Sealing Material it 501 - - Depth -<'•Filter Material (Below 501' f - TYPE OF SEPTIC WORK: -NEW INSTALLATION . REPAIR/ DDITION 1 1, DESTRUCTION I I (No Septic system permitted if public sewer rs available within 200 feet.) f' ' Instillation will serve: Resilience_ Commercial_ _Other if r Number of living units: Number of bedrooas7�t ti 1s4 Character of soil to a depth of 3 feel: t,�.. � ..,,11 Water table depth SEPTIC TANK` ;� •. ,�,Type/Mfgx �%- _ � U( No. Compartments 7� PKG.•TREATMENT-PLT. ❑ • " ""�`. _ Method of Disposal PIOIN41 15EI> - . 'Distance to nearesl:. rWell s�{G_L Foundation )0 -4' Property Line w '9 X`el 9 Total len LEACHING CINE:-- ❑ No.&Lengtngf fine's ' ��,t1. / gth/size FILTER BED ' _J•1�. Distance to nearest:' ' Wella Foundation /0 + Properiy,Line SEEPAGE PITS I I Depth Size Number J Zi ' SUMPS . ❑_Distance.to nearest: = Well- Foundation Property Line f � DISPOSAL PONDS ❑ - +� - • ~ - ' 1 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 lfte San'JoaquiA Local Health 51trict. - - _ 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 c6mpensation 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 Callfornia," The applicant must ll r i d inspections. Complete drawing on r rhe we. r Signed X.AVOW, Title: / Date: o V FOR DEPARTMENT USE ONLY nn�nI L Application Accepted by Date ' V��a Area Pit or Grout Inspectio Date Final Inspection by Date Additional Comments: - ❑ Stk 466-8781 ❑ Lodi 3833821 ❑ Manteca 823-7104 • ❑Tracy 835£3BS Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Silk., CA 95201 WFO AMOUNT DUE AMOUNT REMITTED I CASH RECEIVED BY DATE PERMIT'NO. �.EH 1124 IREV.1/x51 EYI 1418 / /J