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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E, HAZEL T Old AVE., STOCKTON, CA Telephone (209) 466.6781 PERMIT EXPIRES T 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 Soagi;in County Ordinance No.549 to, sewage or No.1862 for wellipump and the Rules and ReC,ulations of the San Joaquin Local Health District. r � Job Address ✓'�1 _ V �. ..!� Cky. Lot Size PM Phone Owner's Name �0>+ i Contractor ��G �r -- Address._ �?< f cfc�. L:tense ..._Phone . TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLACEMENT C, DESTRUCTION L PUMP INSTALLATION i SYSTEM REPAIR 17, OTHER ::_7 DISTANCE TO NEAREST: SEPTIC TANK - _. SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION _._ __ AGRICULTURE WELL OTHER WELL PITSISUMPS INTENDED USE TYPE OF WELL PROBLEM AREA c6NSTRUCTION SPECIFICATIONS ❑ Itlttitstriaf 0 Open Bottom 7 Manteca Dia.of Well Excavation Dia. of Well Casing 0 Dam"t c/Private Ci Gravel Pack L-1 Tracy Type of Casing-- Specifications d1 Pubric— .,... _ ., _I:I.Other",_ .r_.I_r.Daita. ._. - ,.Depth.of Grout Seat _Type of,.Grout 'I ' iAlation --Approx. Depth i I Eastern Surface Seal Installed by _- Repair Work Done C..:7 Type of Pump H.P._—_ _— State Work [lone Well Destruction :a Well Diameter _ Seating Material atop -Nl'l W. -- Depth Filler Material l8alow 501 TYPE OF S01TIC WORK: NEW INSTACIATION i REPAIR IADDITION I OfuSollTRUCTiON I i Mo septic ystem Permitted it public .ewer is. avaitabfe`w{th 2{X7 ee&- '.. �ec.'_7:.;.i�-�-`f�.�.•�.e'••�-T- . .. ' - ��._.. ;... w:., .:..:..lr'y,""t'ry"`"` "T;,-_•�+n:. ti tnstasiation will,erne Rrs rine Commercial__ "7thor a Number of living units: � Nurnber'of Uadronm�sp�.�.� Character of soil to a depth of 3 feet:�...___.._�>W'L! _ _ Water table depth SEPTIC TANK n ,Type/Mfg .___ .. Capacity No. Compartments _� �2. _._..._ PKG. TREATMENT PLT.C r; Method of Disposal _---- -. Distance to nearest: . Well�� ......_ Foundatinn _.._. _ Property Line . ^ ....... -...... ._ ._.,.,.._......�. ._.. LEACHING UNE i l No,8 Length of itnes ✓� ��--� Total lengzhlsize __�- W FILTER BEL} Distance to nearest: Well Foundation�� Property Line. _ _ __ Pu SEEPAGE PITS ( l DepthSize _.__, t ._..1 Number_..___..._ SUMPS I I Distance to nearest: Well Foundation J Property Linc 1� t DISPOSAL PONDS Li I heteby 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. i .....�...i ' Home owner or licensed agents signature Certifies the following:"I certify that in the:rparfonrrance Of the work for which this permit is issued,.l shall not employ any person in such manner as to becorne subject to workman's compensation saws SY-Ciiifnrnia."Contractor's hiring or sub-contracting signature certifies the followirto:"I Certify that in the performance of the work for which this permit is isided,I shall employ persons subject to workman's comoensa- tion laws of California," 17 The applicant must 1 for&4 required inspections. Complete drawing on reverse Sidi), Signed X_ Oate:Title: ., y�L�`r4� '�!'. '•r a,,..!— FOR DEPARTMENT USE QNLY�_ t, Application Accapted by �* Bata __ -- Pit or Grout lnspactiort by Date Final Inspection by��A of- Oate�� ✓ •Additwiial;Camrrwrits: _.. l Stk 466-6781 C Lodi 359.3621 O Manteca 823 7164 '' 1 3 Tracy 835.6385 Applicant • Return,all copies to: Envirohmeritai Heahh Permit/Services 16111 E. Hazelton Ave., P.O. Box 2076, Stk., CA 95Mt FEE AMOUNT DUE AMOUNT REhMtTTED CK REC�IYED .INFO .CASH...... t EM tf•2e I t ,j }