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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT P AYMEN� 1601 E. HAZELTON AVE., STOCKTON, CA REGEtVD Telephone (209) -466-6781 1g 3 PERMIT EXPIRES 1-YEAR FROM DATE ISSUED j�ljtl� (Complete in Triplicate) ^r�`` NTAL 111"ITH Application is hereby made to the San Joaquin Local Health District for.a permit to construct and/or install the work her[iLirt�e19Q9a• n is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and ReguW91 `Joaquin Local Health District. J�L- �oct� City 5'11PiCfcl�Yl Lot Size y �� etc re-PM Job Address / Owner's Name s/vt t(9 4-44 / C"! Address sszo SI�'tC/'i� /�fifl r //LRS "'�"e y63 Z?rI si'zLlrti4 !'�CiG DIcI.S'r'C7q 1, i Contractor DT C-Te 6t.K�rZ �CP l e[Gtf d 00O e- LiR• � 7LCrd Lice t se No. -�7Phon �J ��Zig TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES 3Z3 DISPOSAL FLD. PROP. LINE L�L- r� i FOUNDATION AGRICULTURE WELL OTHER WELL �� PITS/SUMPS �Tt- INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 1015- 15"— - Dia. of Well Casing Z I i le-4 !� m otic/Priva e. ❑ Gravel ark ❑ racy Type of Casing vc S, '(0 SDecifications Mnt�r r�1 4yt,zel f b`1�5 ` a he t e/eryatiKP Alc wf Cetvt 1-1 Public !ffl `O``h�r Delta Depth of Grout Seal ' f ype of Grou� . I I Irrigation �_Approx. Depth I I Eastern Surface Seal Installed by C-s•l`o 1 2G Repair Work Done ❑ Type of Pump H.P. State Work DonetJIJJ tM-A.WCrf C5 & 3 f Well Destruction ❑ Well Diameter -� Inf�+ Sealing Material (top 50'1 e, ne J}W� Depth 4,5- Filler Material (Below 501 S tiG TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I 1 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 Y3 lee[: " Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments n� PKG. TREATMENT PLT. ❑ r, 1 Method of Disposal �3 Distance to nearest: vyngfJJ Founda n Property Line LEACHING LINE ❑ No. & Length of lines S' Total length/size + C FILTER BED ❑ Distance to nearest: Well _Foundation Property Line 1 SEEPAGE PITS F] Depth ze Number SUMPS ❑ Distance to nearest: Well Foundation Property Line S DISPOSAL PONDS ❑ hereby certify that 1 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. \v 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, f shall not p employ any person in such manner as to become subject to workman's compensation taws 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 e d inspections. Complete drawing on reverse side. Signed X Title: r�:eG� Date: 3 1 FOR DEPARTMENT USE ONLY ve Application Accepted by Date Area Pit or Grout Inspection by Date Final inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-362f ❑ Manteca a23-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazalton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED K RECEIVED BY DATE PERMIT'NO. INFO CASH �Q ice/ *-EH 13.24(REV.t/115) EH 14-26