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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone 12091 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 wrteVUct and/or install the work herein described. This application is made in compliance whh 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. � Job Address /AX30 "7 Lr fl T. -Mc l�Dp�+� ChyX0✓a"I- _• Lot Size / PM Owner's Name /. Addresa/6nqd I . A QLvr.a`��[�P a Phone b�" s Contractor's Name License No. /�9 -3 Phone �^ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR H' OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION T— AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE Of WELL PROBLEM AREA CONSTRUCTION SPECIFICA IONS ❑ Industrial G Open Bottom i , ❑ Manteca Dia. of Well Excavation ! Dia. of Well Casing 2-'Domestic/-Private--C Gravel-Pxk�-�--0 Tracy--= —Type of Casing ---- - - - - ---Specifications - ❑ Public , ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation ---Approx. Deptfp ,❑—Eastern S ®face Seal Installed by Repair Wdrk Done El Type of Pump J�'^"�' H.P. J^?/ State Work Done 11 Well Destruction ❑ Well Diameter Sealing Material (top So Depth - Filler Material(Balmy 501 TYPE OF SEPTIC WORK: NEW INSTALLATION❑ REPAIR/ADDITION❑ DESTRUCTION ❑ (No septic system permitted if public sewer is 6 i 4 available within 200 feet.) g� Installation will serve: Resider"— Commercial_ Other ' Number of living units:_ Number of bedrooms . 1% 0 Character of soil to a depth of 3 fent: Water table depth. SEPTIC TANK ❑ Type/Mfg CapacityNo. Compartments PKG. TREATMENT PLT.❑ 1 Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. ®Length of fines Total length/size FILTER BED Cl Distance to nearest Well Foundailon Property Line SEEPAGE PITS Cl Depth Size Number SUMPS Cl 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�t 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 1 employ any parson 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 petmit is issued,I shall employ persons subject to workman's compensa- tion laws of California.- The applicant . m { call all Inspections,,Complate,dd'ra�wing on reverse-side. signed XV � ✓ Date: /)/J FOR DEPARTMENT USE ONLY a l Application Accepted by -SP4<2 Date Am / �j ,� cQ Pit or Grout Inspection by Date Final Inspection by�, �/' Dow��7 r Additional Comments: ❑ Stk 46G6'781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-BM Applicant- Return all copies to: Enviromnentel Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 NNW AMOUNT DUE AMOUNTREMnTED CCASH RECDATEE1veo By PERMfT NO. EH a IR".ic,M) y i -�! GN 1L'JI4 b O �� /Ss11 _