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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 11 ' 1601 E. HAZELTON AVE., STOCKTON, CA Telephone 12091 466-6781 PERMIT EXPIRES 1'YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to the San Jo uin Local Health District for a Deimit to construct and/or install the work herein described. This application is made in compliance with San Joaquin County Ordinance No,549 for sewago or No. 19F,2 for wel!'pump and the Hules and Regulalions of the San Joaquin Local Health District, Job Address -_�1 r.._��'+_..^r;[iCity!Y� �/ Lot Size_ PM— s dam. Phone �. Owner s Name _Tri l�.L'-____ Aodress ��'>� �"� � � Cortc2cttx- �o� ...__ Address .`i••w License No.y�3 / Phone. " TYPE OF WELL/PUMP: NEW WELL P WELL REPLACEMENT 7 DESTRUCTION 0, j PUMP INSTALLATION L1 SYSTEM REPAIR OTHER C DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES -- —.._ DISPOSAL FLO.._ PROP. LINE _.. _.._........ —. FOUNDATION .__.. ._.�. AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED LISE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS _..._. C Industrial LJ Open Bottom U Manteca Dia. cf Well Excavation_ .. Dia. of Well acing 0 Domestic/Private 0 Gravel Pack 0 Tracy Type of Casing_ ____ .___... _ Specifications 171 Public f! other i .l Delta Depth of Grout Seal _ Typo of Grout ! I Wigalion r.....,Approu,'Depth I I Eastern Surface Soul Installed by-------11 1 ..... Repair Work Done 11 Type of Pump State Work Don" Well Destruction i:_i Well Diameter 'Sealing Material )top 50'1 _—._._.... �.-..._ .-.. �.----- Depth t Fitter Material lBalow 501 �l 'TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIWADDITION I.l DESTRUCTION I I INo septic system permitted it public sewer is available within 200 feet.) Installation will serve: Residence__..i r Commercial,_ Other Number of living units: _ Number of bedrooms 1 � ^Water table depth .-._ Character of sail to a depth of 3 feet: .. - - t' No. Compartments ' SEPTIC TANK j21 'Type/Mfg —_.. Capacit PKG. TREATMENT PLT'(l } Method of Disposal "tante to nearest: Well?� r Fot tdaiiari;! Property Line LEACHING UNE rgth of lines : i �! No. S Len _ Total lengthJsize __ —.f— ~ FILTER BEDG Distance to nearest: Weil 9W Founciation .� Property Bite ,t t SEEPAGE PITS F1' Depth SUMPS ti illi Distance to nearest: Weil—Yl�O� Foundation Property Litre DISPOSAL PONDS 1 l I hereby certify that I have prepared the application and that the work will be donin accordance with San Joaquin icounty ordinances,state laws, and e rules and regulations of.the San Joaquih Local Health District. Home owner or licensed agent's signatdr,e cenitiBs the following; "I certify that in the performance of the work far which fhis permit is issued, I shall not amp=oy any person in such manner as try!becom4 subject to workman's compensation laws of alifarrria,.",Contract6t's hiring or sub-contracting signature certifies the following:''I certify that in the performance of the work fnr which this permit is issued.I$hail employ persons subject to workman's cornpensa;` tion laws of California ' i , The applicant mus all for ail requited inspacticnsl{ Ccrtnplste drawing on reverse side, D Signed X_... «FO ;. t _. Title:., __� __.__—.._ Date. � FOR DEPARTMENT USE ONLY _ r. _ Dirt` Application Accepted by Area . f Pit or Grout Inspection by _. ' t"Date :-Final Inspection Gate -—Additional Comments: Ci Stk 466.6781 ' .! 2 Lod, 369-3621 11 ManlI '623-7104 Cl Tracy 835- Applicant • Return al(copies to: Environmental Health Perrnit/Services 1601 E. Hazelton Ave„ P.O; Box 2009, Stk., CA 96201 FEE AMOUNT DUE AMt�UN7 REMITT£A RECEIVED BY DATE PERMPf"NO. INFO ------- w�/rt— W1:7/ r . frrt321iREV.r;�5. ' —� JS �! 1:7 9-7 r,7 Em 142e