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APPLICATION FOR PERMIT r SAN JOAQUIN LOCAL HEALTH DISTRICT I 1601 E. HAZETON AVE., STOCKTON, CA Telephone (209) 466-6781 r 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/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. " 1,a ! i Job Address f 6_1?� /V1 City M1') �/Lot Size_Z� PM i Owner's Name �T cul2v—Ca-f A* Address r h d A Phone \ Contractor_ � Address & B, l � -flCLicense NoA 26 Phone 5 �\ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ s1 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE # FOUNDATION AGRICULTURE WELL OTHER,WELL PITSISUMPS INTENDED USE-,, , TYPE.OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS i Industrial 's' = ❑ 0pen'I3ottom i ❑ Manteca Dia. of Well Excavation Dia- of Well Casing t " ❑ Domestic/Private ❑ Gravel Padk ❑ Tracy Type of Casing Specifications t ❑ Public `❑ Other ❑ Delta Depth of Grout Seal Type of Grout E Irrigation' t t f � Approx. Depth —❑-Eastern•=-•--SurfacerSeal=Installed by--- --e Repair Work Done 0" hype of.Pump H.P. State Work Done" " Well Destruction ❑ Well Diamefer Sealing Material (top 50') P z Depth •' � Filler Material iBelow 501 i TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION L DESTRUCTION ❑ INo septic system permitted if public sewer is 1 available within 200 feet.) Installation will serve: Residence_� Commercial ._.Other 41--,.2�, M=;•'�.- 5 Number of living units: Number of bedros �,3__ ___ Character of soil'to a dept' h of 3 feet: Water table depth SEPTIC TANK .i Type'/Mfg 1947_ Cap city No. Compartments i P,KG. TREATMENT PLT. ❑ Method of Disposal i Distance to nearest:-1 Well Found'atio'n, -.-,`.-__'Property Line ; ' ry Y LEACHING LINE, No. & Length of lies 3-`-Tar *' �� Total#lengthlsize i ti -, a cc FILTER BED - �- Distance to nearest: Well� Foundation ,U Property Line 1 '1 � SEEPAGE PITS ❑ Depth r " /Size Number i ' SUMPS % !D to nearestr' Well _ -Foundation Property Line DISPOSAL PONOS. ❑ 'I hsrebq ce'tifythat I have piepared this application and that the workrwill be done in accordance with San Joaquin county ordinances, state laws,'and rules and regulations of the Sari Joaquin Ld_cai Health District. `;�-4��-, Home owner or licensed agent's signature certifies;the-following:".1,certify that in the.performance of the work for which this permit is issued, I shall riot` employ any person in such manner as to becomel,se bjbdQ6 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." _r a yea The applicant,must call f all required inspections.YCor pletei 6v—Ang'orti reverse side. ' Signed X ,—6-e r wa� °"1. Title: �"Date: '; r- 4•7 � 1i f _. s :� ...: - ` .- . � . EPARTMENT USE Q11lLY 1 f Ap1tic6tio'0-Accepted by `a+� " Date Area Pit or Grout Inspection by Date `� i Final Inspection b Date Additional Cbmments: i ❑ Stk 466-6781 ❑ Lodi 369736211 ❑ Manteca 1823-7104t❑ Tracy i 835-6385 J Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 s ................� -- ' r INFO` AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE T PERMIT NO, + EH 13-241REV-1/851 - 4 EH 14-28 .r VVV 000 .