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APPLICATION FOR PERMIT 40 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 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 Joaquin Local Health District. Job Address / 3 7 9& •&z r J5 9—CF_- p /.'•DfAC�ityL// 'Lot Size `PM Owner's Name oicrlPhoneoy p -5p / e5L 'eQSA //1TC 10na'Rarl 4+eo2Ntcd5 tb38ldh� IIIOfly �"a2z� d`¢5 Licer 1Qa--r a Phon Contractor TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION C1 SYSTEM REPAIR 11OTHER X AIA-7 W44- DISTANCE TO NEAREST: SEPTIC TANK —R-50� SEWER LINES DISPOSAL FLO. PROP. LINE -7 FOUNDATION - SD r AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial ❑ Open Bottom If Manteca Dia. of Well Excavation /Or Dia. of Well Casing r• ❑ Domestic/Private a Gravel Pack ❑ Tracy Type of Casing �G P✓� Specifications r B Ml Public 71 Other Delta Depth of Grout Seal Type of Grout (EinF� I I Irrigation ^'JY.ppe�r Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done ell Destruction ❑ Well Diameter _ Sealing Material (top 501 �fau'f" slze "a"- !k MCK,70P11,vc« Depth N907 F uar{Neuf dL{ae eM.�e'1 O-/y5'G ea i 6S/o6b'BW*"rTc i f PQsr!rOP TYPE OF SEPTIC WORK: NEW INSTALLATION I1 REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ C\bdrrc'a-Is _ Other Number of living units: Number o Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg acity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal 1 Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: ell undation Property Line SEEPAGE PITS I 1 Depth SizeNumber SUMPS Ll Distance t earest: Well Foundabd 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 rules and regulations of the San Joaquin Local Health Di§trict. 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 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 permit is issued,I shall employ persons subject to workman's compensa- tion laws of California." The applicant must call ! r all r uired ins a )ions. Complete drawing on reverse side. 1'ro'l e e_I oa ��y� Date: q Signed X �' Title: V /-L �— FOR DEPARTMENT USE ONLY Application Accepted bylgw�a�� Date I I•� Areap�� Pit or Grout Inspection by Date ML Final Inspection by C® 'ETE Additional Comments: Cl Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CASH CK 0 RECEIVED BY DATE PERMIT NO. INFO cam' 'N1An I '7� a.EH 13 24(REV.I I x s) �� g � I,&-, �1�3i� 00"4625 EH N-2a