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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 a' 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 Dist ict. , f'1Nu� 3PI Job Address O .0 SA6Ca1,1 V%f. ^QC^A City I CCAC-L-1 Lot Size PM -7e A /'1 '1 i1 S X06 q Owner's Name To�vrSc`, ,r�� Address Py� �o� '3g� Reyr K� OA _ Phone` to Contractor ✓ Address License NoI.C11-WAUN Phol x!$-13=/ TYPE OF WELL/pump: NEW WELL ❑ WELL REPLA EMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR O OTHER 'i tA W DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICAT)9NS J/ L1 Industrial 0 Open Bottom ❑ Manteca Dia. of Well Excava fon p Dia. of Well Casing O Domestic/Private `4 Gravel Pack Tracy Type of Casing + tic) ` ye— Specifications I'1 Public FI Other fl Delta Depth of Grout Seal Type of Grout I I Irrigation __Approx. Depth I I Eastern Surface Seal Installed by �= _ Repair Work Done L7 Type of Pump �_ H.P. � - tate v ork Done Q_ e Well Destruction C1 Well Diameter ; Sealing Material(top"! AZ 2 �G11��C1Yl Depth 5 ' Filler Material (Below-W4 TYPE OF SEP C WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence— Commercial_ Other m 1 Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation . Property Line LEACHING LINE ❑ No. & Length of lines Total length/size ' FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS L 1 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS Fl 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 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 for all require ctions. Complete drawing o reverse side. Signed X Title: Date: / 5 �v FOR DEPARTMENT USE ONLY Application Accepted by .1" Date /~J Area Pit or Grout Inspection by __ Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 O 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 INFO AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. (�-(' Fu f474 IRFV ��NSI '1 5(l ��cl