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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL'ION AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED (Complete in Triplicate) �ytw uon is Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the wo1 t c rk herein d selb an Joaquin made in compliance with,San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the ERM Local Health District. /7 d City Lot Size Job Address c ! /L/LL i< /c Phone Address Owner's Name It Phone ,rte Contractor NS ,Address _I l7 ,jf]F-.vLicense No. 40 �� NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION C5TYPE OF WELL/PUMP: n� OTHER ❑ PUMP INSTALLATION &Rfier%JSYSTEM R AIR SEWER LINES MOI DISPOSAL FLD. PROP. LINE _ DISTANCE TO NEAREST: SEPTIC TANK FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS INTENDED USE ❑ Industrial M Domestic/ Private M Public 1 1 Irrigation Repair Work Done ❑ Well Destruction ❑ E OF SEPTIC WORK: PM TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Specifications ❑ Gravel Pack ❑ Tracy Type of Casing - _ Type of Grout n Other F1 Delta Depth of Grout Seal �.Approx. Depth I 1 Eastern Surface Seal stlled by ` G __.H P State Work Done Type of Pump Well Diameter Sealing Material (top 50') - nenth Filler -Material (Below 501: = INSTALLATION I 'l REPAIR/ADDITION I I Installation will serve: Residence — Commercial Number of living units: Number of bedrooms _ Character of soil to a depth of 3 feet: SEPTIC TANK © Type/Mfg PKG. TREATMENT PLT. ❑ � a s �- N Distance to nearest: Well LEACHING LINE ❑ No. & Length of lines FILTER BED ❑ Distance to nearest: Other b Well —, TION t I. (No septic system permitted d publFc sewE. available within 200 feet.) Water table aeptn — _. Capacity No. Compartments Method of Disposal Foundation Property Line Total length/size— Foundation Property Line r r . i Number SEEPAGE PITS l I Depth Size Property Line SUMPS L-1Distanceto nearest: -Well Foundation i DISPOSAL PONDS ❑ F will be done in accordance with San Joaquin county ordinances, state laws, and I hereby certify that I have prepared this application and that the work rules and regulations of the San Joaquin Local Health Di§trict. Home owner or licensed agent's signature certifies the followings: "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 1 equir ns. Complete drawing on raver side. Signed X �1 pa Title: te: DEPART ENT USE ON Y c Date �� r �O Area Application Accepted by Data Final Inspection by Date Pit or Grout Inspection by em Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca B23-7144 Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk„ CA 95201 FEE CK RECEIVED BY DATE PERMIT' NO. INFO AMOUNT DUE AMOUNT REMITTED CASH R �g ass +.EH 13-241pEv. t/n5) EH 14.28 f r; APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL'ION AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED (Complete in Triplicate) �ytw uon is Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the wo1 t c rk herein d selb an Joaquin made in compliance with,San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the ERM Local Health District. /7 d City Lot Size Job Address c ! /L/LL i< /c Phone Address Owner's Name It Phone ,rte Contractor NS ,Address _I l7 ,jf]F-.vLicense No. 40 �� NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION C5TYPE OF WELL/PUMP: n� OTHER ❑ PUMP INSTALLATION &Rfier%JSYSTEM R AIR SEWER LINES MOI DISPOSAL FLD. PROP. LINE _ DISTANCE TO NEAREST: SEPTIC TANK FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS INTENDED USE ❑ Industrial M Domestic/ Private M Public 1 1 Irrigation Repair Work Done ❑ Well Destruction ❑ E OF SEPTIC WORK: PM TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Specifications ❑ Gravel Pack ❑ Tracy Type of Casing - _ Type of Grout n Other F1 Delta Depth of Grout Seal �.Approx. Depth I 1 Eastern Surface Seal stlled by ` G __.H P State Work Done Type of Pump Well Diameter Sealing Material (top 50') - nenth Filler -Material (Below 501: = INSTALLATION I 'l REPAIR/ADDITION I I Installation will serve: Residence — Commercial Number of living units: Number of bedrooms _ Character of soil to a depth of 3 feet: SEPTIC TANK © Type/Mfg PKG. TREATMENT PLT. ❑ � a s �- N Distance to nearest: Well LEACHING LINE ❑ No. & Length of lines FILTER BED ❑ Distance to nearest: Other b Well —, TION t I. (No septic system permitted d publFc sewE. available within 200 feet.) Water table aeptn — _. Capacity No. Compartments Method of Disposal Foundation Property Line Total length/size— Foundation Property Line r r . i Number SEEPAGE PITS l I Depth Size Property Line SUMPS L-1Distanceto nearest: -Well Foundation i DISPOSAL PONDS ❑ F will be done in accordance with San Joaquin county ordinances, state laws, and I hereby certify that I have prepared this application and that the work rules and regulations of the San Joaquin Local Health Di§trict. Home owner or licensed agent's signature certifies the followings: "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 1 equir ns. Complete drawing on raver side. Signed X �1 pa Title: te: DEPART ENT USE ON Y c Date �� r �O Area Application Accepted by Data Final Inspection by Date Pit or Grout Inspection by em Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca B23-7144 Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk„ CA 95201 FEE CK RECEIVED BY DATE PERMIT' NO. INFO AMOUNT DUE AMOUNT REMITTED CASH R �g ass +.EH 13-241pEv. t/n5) EH 14.28