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APPLICATION FOR(PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-8781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) 11 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. 161110 14o K N�11 1 RD Job ddress city 6n264<n2/4V Lot Size !��D JC 1,60 , PM �7�^ y Owner's Name c.00 L Address Z b 157POVER 1 14- Phone �,�— Contractor G RCS 2 +L U Address HYD SD P I,K G L�+ 1 e f dcQ nse No. X13`�.�Y3__Phone`'�s d -zj TYPE OF WELL/PUMP: NEW WELL IR WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES it DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL EI OTHER WELL PITS/SUMPS \ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS (� ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well,Excavation 1 Dia. of Well Casirr�� ❑ Domestic/Private Gravel Pack ❑ Tracy Type of Casing P+ Specficatiorrs . OZiD t nlz ❑ Public WIj, LrA❑ Other ❑ Delta Depth of Grout Seal I OPT AJ Type of Gr t ��✓� ❑ Irl( ll o WELL ,��pprox. Depth ❑ Eastern Surface Seal Installed by Sr P 4 l� 2t r`c i+NG Repair Wolk%one ❑ Type of Pump H.P. J State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material(Below 501) TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is P 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 Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundatioi n Property Line LEACHING LINE ❑ No. & Length of lines i Total length/size FILTER BED Q Distance to nearest: Well Foundation Property Lina l y SEEPAGE PITS ❑ Depth Size ,l Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ .I t hereby certify that I have prepared this application and that the work will be done in accordance with SanCiupin a laws, and rules and regulations of the San Joaquin Local Health District. ii Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the w is i ed, I shall not employ any person in such manner as to become subject to workman's compensation laws of California."Cb-cont_ting signature certifies the following: "I certify that in the performance of the work for which this permit is issued,I shall emct to workman's compensa- tion laws of California." I The applicant mus cat)for 41 req nspection Complete drawing on reverse side. f Signed X l^ Title: 1 /` , Date: IUSE NLY f Application Accepted b Date Area Pit or Grout Ins ti y Date Final Inspection by Date Additional Comments1'� 6 ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6386 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA95201 " FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. ♦ EH 13-21(REV.+i e sl C-0 �• 1 Q�—� . EH 11-26 V' �