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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�-A 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 Jo Local Health District. (' Joaquin Job Address p00a� Wo, �, d � /`'� City L i tiAe.V� Lot Sae D� 96-c_j PM 1 Owner's Name r U-/VTLy{�Addre,w 6 2f56G3 SG 3 �� 7 ^yam r}�J Phone Contractors Name ADCC t l"f S2 eene No. TYPE OF WELL/PUMP: NEW WELL �7 Phone WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMPINSTALLATION P--� SYSTEM REPAIR ❑ DISTANCE TO NEAREST: SEPTIC TANK �_ SEWER LINES Z°O0, r OTHER ❑ DISPOSAL FLD. PROP. LINE _ FOUNDATION 'lnr i- AGRICULTURE WELL a OTHER WELL INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS PITS/SUMPS In?uginal Open Bottom ❑ Manteca Dia. of Well Excavation a M Domestic/Private O.Gravel Pack ❑TracyDia. of Well Casing ❑ Public Type of Casing i=r v l_ Specifications ❑ Other ❑ Delta Depth of Grout SI ❑ Irrigation y/�r � Seal '9 o�JtPProx. Depth ❑ Eastern Surface Seal Installed by�� Type of Grout Repair Work Done ❑ Type of Pump / H.P. 4 State Work Done Well Destruction ❑ Well Diameter - Sealing Material (top 50'! Depen Filler Material (Below 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (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 soll to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity - - No. CompartmentsC PKG. TREATMENT PLT. ❑ _ ' , Method of Disposal Distance to nearmt: Well Foundation - 'property Liner - t - t LEACHING LINE ❑ No. 8 Length of linin Total length/size FILTER BED ❑ Distance to nearest: ,„Well Foundation Property Line SEEPAGE PITS ❑ Depth _ Size Number SUMPS O Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that 1 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 cartifies 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 subcontracting 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 compense- i tion laws of California." The applice must for req 'red inspections. Complete drawing on reverse side. r C r & �r-1 yrI Signed X Title: G M , - � J S t 6T Date: RD A M BE ONLY Application Accepted by Date Z 2�Area Pit or Grout Inspe o y _ Data Inspection by Daft Additional Comments: ❑ Stk 4666781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835413115 Applicant - Return all copies to: Environmental Health Permit/Services 1801 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED OKs RECEIVED 0Y DATE PEflMR NO. NFO CASH