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iAPPLICATION 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) described. This all the work-her madec ncation is conmis erebyplliance writh SanoJoaquinthe SanCouJoanty Ord nauin Localnce Nto.549 for sewage oriNo. 1862 forcwell/dpump atnd the Rul s and gulations of the San'Joaquin Local Health District. hQ �1 D� - — t^n -_ZO .iC . city— -- Lot Size Job Address z , i'- ry 2-C7 �lot'l r,n t, ;toc' tion 7f1.. ", I-1.717 Phone Address Owner's Name p _ _ License No _- Phone- ---- -- - Address WELL REP Contractor - DESTRUCTION ❑ NEW WELL ❑ LACEMENT ❑ _ TYPE OF WELL/PUMP: OTHER © PUMP INSTALLATION ❑ SYSTEM REPAIR 11 DISPOSAL LLD. PROP. LINE DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES SeqC! FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS p3C INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing ❑ Industrial Open Bottom © Manteca Dia. of Well Excavation Specifications Type of Casing -- ❑ Domestic/Private _0 Gravel Pack El Tracy ^i ? Type of Grout FI Public -- _71.0ther n Delta Depth of Grout Seal _ 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 Sealing Material (top 501 Depth Filler Material (Below 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION 1 1 DESTRUCTION I I availaeptic system m rented if public sewer is le Installation will serve: Residence_ Commercial_ Other Number of living units: _ Number of bedrooms Water table depth Character of soil to a depth of 3 feet: Capacity No nM�Yy %{ N-r SEPTIC TANK ❑ Type/Mfg PKG. TREATMENT PLT. ❑ Distance to nearest: Well Foundation Propertyrl.p rrC Total len A419JOA0UIN 001INTv LEACHING LINE ❑ No. & Length of lines ALTH SERVICES FILTER BED ❑ Distance to nearest: Well Foundation_ I LTH DIVISION SEEPAGE PITS I I Depth Size Number SUMPS 0 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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 Di1trict. 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 required inspections. Complete drawing on reverse side. • Signed K Title: B (.t/-) Date: 2 • / 9- S�— FpR DEPARTMENT USE ONLY I� ^ �?� 1 1 Date •Y—' Area— Application rea CJ Application Accepted by 3 �-- Pit or Grout Inspection by Date .3 �" Final Inspect10 by Date 5b9 Sa`� C 0 ' 3),3 �- �3 ru�1 Additional Comments: q C ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-71044 ❑ Tracy 835-6385 l 11 J Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE CK RECEIVED BV DATE PERMIT NO. PI DUE AMOUNT REMITTED CASH INFO EH j}N(REV.I sv �— EH 14-M