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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT r� 1601 E. HAZEL T ON 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 Loca! Health District fora permit to construct and/or install the work herein described. This application is made in compliance with San Joaquin Countf"i O'r'dinance No. 549 for sewage or No. 1862 for well pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address N GP`s M_r`''t''Q/4 L-^J 1A1 06 Nr"'y-` 9 City SIGC9-7Gr4 Lot Size PM '7212 n'h+ V.�-ri-I v of 4/ Owner's Name v r C Address Phone 6 Contracto "� +.rsr1 !r.+�f Address x0'14 LE - to ense No.rl � 7�i� Phone 13 41,5 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR 0 OTHER y9 TEg" &CIZJAIFj DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUcMPS 5 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 16 *0 , r O's E10 D Industrial If Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications FI Public C1 Other n Delta Depth of Grout Seal Type of Grout —_. I ] Irrigation -Approx. Depth t 1 Eastern Surface Seal Installed by An MC1Pr?Y£ i7Qy 1f�L Repair Work Work Done ❑ Type of Pump H.P. Siete Werk"f)vte{� ln�/9l?4fI �Ur.lF_j F Well Destruction ❑ Well Diameter Sealing Material (top 50') GuIEL Depth Filler Material (Below 50') DI TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION i I DESTRUCTION l I (No septic system permitted if 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 ❑ Type/Mfg _ Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS t I Depth Size -Number SUMPS ❑ Distance to nearest: Well Foundation Property Line 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. Horne 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." Contractors hiring or sub-contracting signature certifies the following:"1 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 must call fo uired inspections. Complete drawing on reverse side. Signed X n Title:PCsi2-:� T 66081E ,S:_1---- Date, *2 SF R DEPARTMENT USE ONLY (� Application Accepted by Date /,/S ___ Area' Pit or Grout Inspection by Date Final Inspection by Date Additional Comments:,1 ----r— ❑ Stk 466-6781 ❑ Loi 369-3621 ❑ anteca 3-7104 ❑ Tracy --- ---- Applicant- Return all copies to: Environmental Health Permit/Services 16D1 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT'NO. INFO 1.r EH 13-24 1REV.1/"51 EH 14-29 .._..-_. _-