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u APPLICATION FOR PERMIT 1%.01 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 Distriicctt.. 1 mcg f ,b h \. �c1.�rty— Cl p Job Address v 0 ,, '�71 / I-A 49 ;1,7�� 1 City 4d©p 7 �yLot Size PM Owner's Name A9 Al br' r ,Ir Q? L/ f Address 9v ` AI `iow ED Phone 1 7f / 1 w Contractor�/O in71, V d 1-LC rDI7�7tddress O /M License Noy/ a 3 C PhorlE O �y r TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER g AfOA17 fp n IV4_L4<' DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE — .05 - FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS `J/ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing l/ ❑ Domestic/ rivet gtGravel Pack ❑ Tracy Type of Casing P V_ Specifications PO A y M M Public F1 Other ❑ Delta Depth of Grout Seal tt4 1J /A L r Type of GroutJPg- K I I Irrigation —Approx. Depth I I Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump — H.P. State Work Done ''�� (( Well Destruction ❑ Well Diameter zl Sealing Material (top 50'1 pO/5 f &js-D CF a,�J✓�A4k Depth _YA&I-4-- � Filler Material (Below 501 SAKI 0 r{4 R,Orr! A/k. /A+ .( TYPE OF SEPTIC WORK: NEW INSTALLATION 11 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 Number of living units: _ Number of bedrooms / Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg CapacityNo. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line C 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 ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 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 at call for all required i P Cions. Complete drawing on reverse side. Signed X Title: Date: — 2— FOR DEPARTME T USE ONLY Application Accepted by Date dzhl Area �� Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 Cl 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 EH 1426 AMOUNT DUE AMOUNT REMITTED OK R�EC�E-I}V-EDD BY DATES PERMIT'NO. a EH 13N tRrv.rrxsi 3sa O `/\ 1vao