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APPLICATION FOR PERMIT , ' SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 5 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. This application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for welllpump and the Rules and Regulations of the San Joaquin Local Health District. t. Job Address W �� City��r— Lot�SQize J PM -- 3,0 Owner's Name 4/f\ Address 3.rF l��tC,_ Phone�_ � d Contractr/�d6Z._ ( -Address`� lP7 '�`�' "` License No. ��a Phone TYPE OF WELL,'PUMP: NEW WELL C WELL REPLACEMENT 11 DESTRUCTION Ci "PUMP INSTALLATION 71SYSTEM REPAIR,L7 F. .,...-OTHER_❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES _ DISPOSAL FLD. PROP. LINE - !- FOUNDATION __ AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS El industrial [3-Open Bottom - 71-Manteca Dia. of Well Excavation Dia..of Well.Casing. C Domestic/Private 0Gravel Pack ❑Tracy Type of Casing _ _ Specifications a Type of Grout f". Public L1 Other ❑ Delta Depth of Grout Seal -- Ly ' I I Irrigation _..Approx. Depth I Eastern Sutface Seal Installed by__ - Repair Work Done ❑ Type of Pump _ H.P. _ State Work Done _Well Destruction C Well Diameter �-- ---Sealing Material.I top-501. ---- Depth __ " ^- ller Material (Below 50'1 -- TYPE OF SEPTIC WORK: NEW INS�TAALLL .LATION I REPAI !ADDITION l DESTRUCTION i 1 al No- a tttwithin 200 i permit ed it public sewer is Installation will serve: Residence _ Commercial— Other Number of living units: �L� Number ofbe r oms Character of soil to a depth of 3 feet: _. Water table depth ,2._ SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PIT. ❑ F Method of Disposal Distance to nearest: Well _— Foundation Property Line LEACHING LINE L No. S Length of lines _ ___ �._ -- Total length/size -- i FILTER BED ❑ Distance to nearest: Well r+� Foundation_jam Property Line II{t SEEPAGE PITS 'I Depth _.1D Sixe_�'1 .-..._. Number ......_ c .. .. _`� _ SUMPS (ct*"Distance to nearest: Well. SQL-. Foundation /4 _.. Property Line e i DISPOSAL PONDS 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 signature certifies the following: "I 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 applicant m call for req led inspections. Complete drawing on reverse gide. t__ (J � f Signed-X Title:—AL,--� Date: i FOR DEPARTMENT USE ONLY App'.ation Accepted by ^Cy ,y tdy Date m2� Area a -T i "�` `/! Date�� 1 �,.. or Grout Inspectron by �Date� — Final Inspection by±� r� Additional Comments: f ❑ Stk 466-6781 F Lodi 369.3621 ❑ Manteca 823-7104 G Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Silk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED ASH RECEIVED BY DATE PERMIT NO. INFO EH 13-24(REV.I I r.51 EH 1426