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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT" 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone 120-91 466-6731 PERMIT cXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a perm't to construct and/or install the work herein described.This aP"alicatj n is ma(:e in compliance with San Joaquin County Ordinance No.549 fcr sewagf)or No 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. r ` n / Job Address � � L �/�� Cry��l>>� Lot Size PM Owner's Named Address 1:12 M J7-1-10117`,C1 'lJ/oC/ i-- phone Phone Contractor�4� � Address�?CS-�='�Cll� A _License Nc. �� J Z/ "� � � � ` � � tt TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT C DESTRUCTION ❑ v h PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ \( 1 DISTANCE TO NEAREST: SEPTIC TANK — SEWER LINES DISPOSAL FLD. PROP. LINE 1 FOUNDATION _ AGRICULTURE WELL ___ OTHER WELL__ PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS U Industrial ❑Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing _ ❑ Domestic/Private ❑ Gravel Pack ❑Tracy Type of Casing = Specifications 11❑ Public Other ❑ Delta Depth of Grout Seal Type of Grout .4 ❑Irrigation _Approx. Depth ❑ Eastern Surface Seal Installed by rRepair Work Done G Type of Pump _ H.P._ State Work Dona _ r Well Destruction ❑ Well Diameter Sealing Material(top 501) _— Depth FJler Material IB91ow 50') TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION 17 DESTRUCTION Ci (No septic system permitted if public sewer ism t / available within 200 feet.) y Installation will serve: Residence_ Commercial V Other Numbnr of living units:__ Number qWiedroo S. 1 Character of soil to a depth of 3 feet: ' 4 Water taLle d3pth 5� / SEPTIC TANK L Type/Mfg,�Df/ taw& v paciry r-1261�, No. Ccmpartments \. PKG. TREATMENT PLT.❑ r Method of DDii�sposal _. v Distance to rcarest: Well CyV0 Foundation /0 Property Line LEACHING LINE 9+'-No. &Length of lines .p ._ Total length/s:ze__ Q FILTER BED C Distance to nearest: Well� Foundation IO Property Lire SEEPAGE PITS ❑ Depth _ _Size__ Number SUMPS C^f''Distance to nearest: Well Foundation_�_ Property Line DISPOSAL PONDS ❑ /w 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 tnis 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 sifinature 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 cornponsa- tion jaws of California." The applicant must cal for ei required inspections. Complete drawing on reverse side. YC/�f Signed"--f"�^-b''�' � _-- Title: � GU�fJ�J Date: - FOR DEPARTMENT USE ONLY //�� Ap,..�cation Accepted by _ Date (D Area Pit or Grout Inspection by` Date Firal Inspection by Date1 V Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 U Trac 835.0385 Applicant- Return all copies to: Environmental Health Permit/Services 1501 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 INFO AMOUNT DUE AMOUNT REMITTED CASH CKs RECEIVED VY DATE_ P98MIT NO. ♦ EN 1131 U1Ev.i'nv I�� j db�1433 EN 1420