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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 a k 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 Local Health District. application n Joaquin Job Address city �� V'� rC..r Lot Size`5U PM Owner's Name i SS i Address �� Phone �6 371 Contractor cnUc Address TYPE OF WELL/PUMP: NEW WELL ❑ �1m�J License No. Phone 9� g PUMP INSTALLATION WELL REPLACEME EJNT ❑ DESTRUCTION ❑ + 5 SYSTEM REPAIR C] OTHER ❑ •,DISTANCE.TO-NEAREST: SEPTIC TANK a SEWER LINES DISPOSAL FLD. FOUNDATION PROP. LINE - — � AGRICULTURE WELL OTHER WELL INTENDED USE € t TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS PITS/SUMPS ❑ Industrial t �.Open Bottom ~�—� i. ❑ Manteca Dia. of Well Excavation ❑ Domestic/Private ❑ Ga:avel Pack Dia, of Well Casing y' M PiJII s, ❑ Tracy Type of Casing"" -... n Other n Delta s Depth of Grout Seal Specifications_ „ I I irrigation '�APpro>ii Depth 1 ) EasternTVPe of Grout' } Repair Work Done I❑::,Type`of Pump Surface Seal Installed by e Well Destruction -❑ ,•_ H.P.Wel! Diameter State-Work Done, Sealing Material Itop 50'1 i Depth Filler Material (Below 50')c TYPE OF SEPTIC WORK: NEW INSTAL TION I;I REPAIR/ADDITION y } _ DESTRUCTfON ! I (No,septic system permitted if public sewer is available within 200.feet.) Installation will serve: Residence '':'Commercial, Other Number of livingunits: I' —"`—� -�— Number of-bedrooms Q, N - Character of soil.to a depth of,3 feet: I / " � 4 SEPTIC TANK ❑ Type/Mfg: _ Wafe-r table depth 0 TREATMENT PLT. ❑: Capacity U No. Compartments �.. {{ Distance to nearest: Well Method of Disposal 1 Foundation _ Property.Line _ LEACHING.LINE .CNo. & Length of lines Q FILTER BED "` _ Total length/size— - - - - J ❑ bistance to nearest:`" Well oun FdationO r —,�—� Property Line_30 t SEEPAGE PITS I'I Depth I F Slze SUMPS Number [.l Distance to nearest: well DISPOSAL`PONDS Foundation Property Lind LQ 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 td workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the parformance 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 Cali for all required inspections. Complete drawing on reverse side.. Signed X LL Title: \ Date- .--FOR. ate:..,_..:,,, —FOR.DEPARTMENT USE ONLY Application Accepted by Date Area CS Pit or Grtiut Inspection by Date Final Inspection by Date 0 Additional Comments;_ Stk 466-6781t LJ 369-3621 ! 1 - O`G t ❑.Manteca r 823-7104 ❑ Tracy 835-6385 pplicant - Return all copies to: Environmental Health hermit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 t I' .f. FEE A INFO AMOUNT DUE` i`-AMOUNT REMITTED -- meq' ?y�� -`-CASH= —RECEIVED BY DATE PERMI7N0. t.EH 1 -24 fREV.ties) •I'U /// - - EH 144-28 {