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,. k ' APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT S 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 486-6783 ��p � Q PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) srW -''�T1""� w Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the orkei described. This application i her made compliance with San Joaquin County Ordinance No.549'for sewage or No1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. . Job Address 1'`)" %110- City Lot Size PM —• ( ! Owner's Name � ! tC 1 dress Phone f Contractor Address �� YPE OF WELL/PUMP: License No. Phone NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION El NEW PUMP INSTALLATION SYSTEM REP El TO NEAREST: SEPTIC TANK OTHER ❑ SEWER LINES DISPOSAL FLD, PROP. LINE FOUNDATION GRICULTUR ELL OTHER WELL INTENDED USE TYPE OF WELL PROBLE R PITS/SUMPS CONSTRUCTION SPECIFICATIONS r ❑ Industrial . D Open $ottom- ❑ Mani Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack i'1 Public © cY Type of Casing (] OtherSpecifications - Delta epth of Grout Seal l,Approx. Dept I I Eastern S ce Seal Installed by Repair Work Done ❑ Type of Pump H P Well Destruction _ State Work Dane_ ❑ Well Diameter Sealing Materia! (tap 50') ' TYPE F SEPTIC WOR Depth Filler Material /Below 50'a K:- (� ONEW INSTALLATION 1.1 REPAIR/ADDITION I ] DESTRUCTION (No septic system permitted if public sewer is } Installation will serve: 'Residence_ Commercial Other Vllvailable within 200 feet.) + Number of living units: Number of bedrooms l Character of soil to a depth of 3 feet: S x SEPTIC TANK ❑ Type/Mfr Water table depth g PKG. TREATMENT PLT. ❑ Ca pacit y No. Compartments ^ ' r Method of Disposal Property perty L Distance to nearest: Well Foundation N _ _ Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line ► '9 SEEPAGE PITS I I Depth Size SUMPSCl DiNumber Distance to nearest: Well Foundation DISPOSAL PONDS El Foundation Line 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 em to y tion laws of California." P y persons Subject to workman's compensa- The applicant m call for all required.. spe (� ete drawing on reversg si e. ! �i, Signed X �/r/� i/L} Title; � t•�--v Date: R DEPARTMENT USE ONLY Application Accepted by. (�^ „ Date _! Area Pit or Grout inspection by Date -_in inspection Date Additional Comments: T ;7,1/ ❑ Stk 466-6781 0 Lodi 369-3621 0 Manteca 823-71040 Tracy ¢ / Q�6 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazeltan Ave., P.O. Box 2009, Stk.,"CA 95201 &, FE 1 A 617,196 INFO MOUNT DUE AMOUNT REMITTED CK RECEIVED 8YjDATE PERMIT'NO. + EH 13-24(REV 1iK51 d(J �'�` t=H 14-28 f;' 6-, -3.