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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT j 1601 E. HAZE.t ON AVE., STOCKTON, CA 1 Telephone (209) 456-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED (Complete in Triplicate) , This (,cation is /or install the work Application s hereby made too San Joa .urn Local Health District for a Counnq ty Ordinance No.549 for sewage or permit No. 1862 for wellldpump and the Rules and herein R Regulations of the S n Joaquin made in compliance with Sann Joaquin I` Local Health District. s`� 193✓ So. :'0r r&9 4, H o L La rid 0� city Lot Size PM Job Addressr` ]�f �fr�� ya/, R,NCJfW CPhone �_ - • 'A�� D� Address rxO�� Owner's Name Jr, b.� r�V IW �10p• License No. y�y"$` / Ph,, d Contractor N� #N f SO Address - DESTRUCTION ❑ NEW WELL ❑ WELL REPLACEMENT ❑ TYPE OF WELLlPUMP:� SYSTEM REPAIR ❑ ,. OTHER ❑DUMP INSTALLATION L) SEWER LINES _ DISPOSAL FLD. POOP, LINE DISTANCE TO NEAREST: SEPTIC TANK PITS/SUMPS FOUNDATION AGRICULTURE WELL OTHER WELL INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia of Well Casing Open Bottom ❑ Manteca Dia. of Well Excavation ❑ ❑ Industrial Specifications u Type of Casing LD Domestic/Private L-1 Gravel Pack ❑ Tracy Depth of Grout Seal Type of Grout — n Other n Delta [-1 Public Surface Seal Installed by ` 11 Irrigation _..Rpprox. Depth I ! Eastern H. State Work Done h e of Pump Sea {J1 Repair Work Done ❑ Type Material-(top 50") t Well Destruction ❑ Well Diameter Sealing - Depth Filler Material (Below 50') C TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPALR/ADDITION I !, DESTRUCTION availablN. etrwi hin 20c system 0 feet.)ii public sewer is installation will serve: Residence Commercial Other_�-- Q j Number of living units: Number of bedrooms Y Water table depth I Character of soil to a depth of 3 feet: ' r/eO x.00 641 z No. Compartments SEPTIC TANK ❑ Type/Mfg Capacity_.L—�--- r I ! Method of Disposal � PKG. TREATMENT PLT.❑ ' t Distance to nearest: Well Foundation _Property Line f " O ! r Total length/size LEACHING LINE Ll No. & Length of lines v FILTER BED F ❑ i Distanc,6 to ne est:, Well Foundation Property Line SEEPAGE PITS { l Depth r° . Size Number I Ll Distance to nearest: Well 'y Foundation Property Line SUMPS DISPOSAL PONDS ❑ " I hereby certify that 1 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 Di§trict.t 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 signature employ any person in such manner as to b me subiect to workman's compensation laws of California." ploy ersonsrring or sub subject to woorkman'rscompensa- certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ p 1 i tion laws of California." i The applicant m t call for all required inspections. Complete drawing on reverse side. —�y~g' Signed X Title: Date: FOR DEPARTMENT USE ONLY Date f Area {Q Application Accepted by Date Pit or Grout Inspection by Date Final Inspection by f Additional Comments: � [I Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 i Applicant , Return_alV.copies.to:-Environmental.Health Permit/Services.1601 E. Hazelton Ave:, P.O.Box 2009;-Stk.,-CA 95201— + CKRECEIVED BY;}f DATE PERMIT NO. FEE AMOUNT DUE AMOUN(T�REMmITTTED nay �.. , INFO +.EH 13-24 1REV.1/n 5; !/ l EH 14-28