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APPLICATION FOR PERMIT " 1 SAN JOAQUIN LOCAL HEALTH DISTRICT 1 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 I nit 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. 1662 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. 1 Job Address C��T TV('1 t=Q ILoA� _ City L- O 1 Lot Size PM Owner's Name1=¢Ya(u= o.r rc' AddressPhone(-)cr- Conlracl�LlWr-+�cuA'tl'��r�d._Address,-}� ��,3�1� 2D Sv1eC� License No `1 ` 1 TYPE OF WELL/PUMP: NEW WELL�K WELL REPLACEMENT ❑ DE PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ DISTANCE TO NEAREST: SEPTIC TANK XJIAL SEWER LINES t-1 00 f:,I- DISP PROP. LIN FOUNDATION AGRICULTURE WELL OTHE '1NELL150 aj� I�I7S/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIO 1 I Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation t3 tv��H N-p(a1.of Wl-W Casing I I Domestic/Private .Gravel Pack ❑ Tracy Type of Casing Nc- UL_�, , sR.1r �r§ �it�boJns "5-M F�t'bC) 1"1 Public ❑ Other Fl Delta Depth of Grout Seal 3S-E t- vE� t Type of Grout.' 1 AC& .. bngauon -__ Approx. Depth I 1 Eastern Surface Seal Installed by C- ,-+r-^'�-- Repair Work Done IJ Type of Pump H.P. State Work Done _ Well Destruction I I Well Diameter Sealing Material hop 501 1 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted it 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 Ll Type/Mfg Capacity No. Compartments PKG. TREATMENT PLL fl Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE 1_I No. & Length of lines Total length/size FILTER BED I I Distance to nearest: Well Foundation.__ Property Line SEEPAGE PITS I I Depth Size ____ _ Number _ SUMPS I I Distance to nearest: Well_-_ Foundation —_ Property Line DISPOSAL PONDS I I 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 signaturecertifies the following: "1 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 nust call t all uinspections. Complete drawing on reverse side. —,�-' Signad X Tide: M'�r/r�-K�'Dr,o t�r�1 Date: 11 �� FOR DEPARTMENT USE ONLY / Application Accepted by Date 3/24 l F� Area Pit or Grout Inspection by Data Final Inspection by Date Additional Comments: ❑ Stk 466-6761 ❑ Lodi 369-3621 O Manteca 623-7114 ❑ Tracy 635-6365 Applicant- Return all copies to: Environ eal ental Health Permit/Services lth Pmit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 INFO AMOUNT DUE AMOUNT REMITTED CKCASH RECEIVED BY DATE PERMIT'NO. . EH 13411aEV.rrnv l_