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APPLICATION FOR PERMIT _ G SAN JOAQUIN LOCAL HEALTH DISTRICT ! � 1601 E. HAZEL T ON AVE., STOCKTON, CAS Telephone (209) 466-6781 6S) * PERMIT EXPIRES VYEAR FROM DATE ISSUED (Complete in Triplicate) b made to the San Joaquin Local Health District for a permit to construcWendlUminsatra�'the Rules and Regulations of he San work herein described, This lJo Joaquin i tion is Application is hese Y made in compliance with San Joaquin County Ordinance No.549 for sewage or.Na. 1862 for p P � Local Health District. Gj s :. City Lot Size PM Job Address �F � Phone j VQ Address . ;owner's Nami k�� •- •-•+� O .t n/1--. ,w- C.i�1c. e; p Phone. a I "y� Alidress � 2� d� License No f Contracto � f..; ,. NE WELL © DESTRUCTION ❑ WELL REPLACEMENT ❑ w;.. ��.,��."� „>•f � Y, � :TYPE OF WELLIPU - ;'"°",^. •� - OTHER'"❑_ s k PUMP INSTALLATION I] SYSTEM REPAIR ❑ 1. x� SEWER LINES DISPOSALFLD"- PROP. LklVE DISTANCE TO NEAREST: SEPTIC TANK AGRICULTURE WELL OTHER"WELL PITSISUMPS -FOUNDATION ' `- 1 INTENDED.USE TYPE OF WELL PROBLEM AREA r -CONSTRUCTION'SPECIFICATIONS Dia C5 . of,. Casing ❑ Industrial j ❑ Open Bottom Manteca Dia of-1'ell Excavation .Specifications ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Ype of Casing Type of Grout i I Public n Other * ❑ Delt -' Depth of Grout Seal e surface Seal Installed by I l Irrigation 4 _._Approx Depth ,-i°I'Eastern Type-oil Pp H.P. State Work Done _—� Repair Work Don ❑ TYP s iol 5ealing.Material (top 50� 1r_ Wel! Destruction ❑. We11�Die�r1 - ; �_ Depth Filler Material (Below 50') / tic 'TYPE OF SEPTIC WORK: NEW INSTALLATION I:1} REPAIR/ADDITION L FSTRUCTIO aNailablPe'w thin 200 1etsystem thed if public sewer is Installation will server Residence� f4ommercial_ Other i Number of living units: Nun+Rerof bedrooms Water table depth Character of soil_ 'to a depth of 3 feet: Noi Compartmer s SEPTIC TANK + ❑ Type/Mfg E Capacity r Method of Disposal PKG. TREATMENT PLT. ❑ t Property Line Distance to nearest: i Well Foundation Total length/size, LEACHING LINE ❑ No. & Length'of lines ! . f Property-,,Line ,:Line ell Foundation k' I FILTER BED ❑ Distance to nearest: W SEEPAGE PITS .Ci Depth t Size Number '. I Foundation Property.,ine (-�I—Di"stance to nearest: Well k, r SUMPS DISPOSAL PONDS ! ❑. + - � a i I hereby certify theta have prepared this applicatiantand that the work wil be done in accordance with San Joaquin count ordinances, state laws, and rules and regulatioriS' the San Joaquin Local4i6alth District. s i Home owner or licensed agent's signature certifies the following: "I certifyl,that in the performance of the work for which this per is issued, k shall not ` '8mploy any person in such manner as to become-46 to workman's compensation laws of California." Contractor's hiring'or sub-contracting signature certifies the following: "I certify that in the,performan`oe of the work for whjptpt0is_,permit is Issued„j,_hall employ persons subject to workman's compensa } t.tion laws of California.” i !The appli7p,oall or all required s cti ns. Complete drawing on re erse side. { a, woo Date; Signed X Title: FOR DEPARTMENT USE ONLY �l 6 Date �Area Application Accepted by Final,lnspecti n by ( Date r Pit or Grout Inspecttio b -. Date _ 1 -. flu 1 Additional Comments: a(A � ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 d Tracy 835-6385 �.'A:pplicant-.Return all copies to: Environmental Health Permitl5ervices 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 �{ E FEE AMOUNT DUE AMOUNT REMIT7E0 ` CK RECEIVED BY DATE PERMIT'NO.. Q I ` + EH1&241RE1/.1/ns) S.w ram �- '�-9 1 EH 14-26