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t APPLICATION FOR PERMIT ��'� SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) k A nation is App Local Ordinance No. is for sewage or No. 1$62 for well/pump and the Rules and Regulations of the San Joaquin ))cation is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This a made in compliance with San Joaquin County r F Local Health District., 2-1� city - Lot Size ?f.� ?M Job Address -J ^ 'y iq C, • vPhone � lldress Owner`s Name � SViTI°OD1� Y1'tiDC}leo , -��Cr..pZ'] License No.. ��Phone Address Contractor WELL REPLACEMENT ❑ DESTRUCTION ❑ `TYPE OF WELL/PUMP: NEW WELL ❑ OTHER ❑ - SYSTEM REPAIR ❑ # PUMP INSTALLATION ❑ DISPOSAL FLD:� PROP.FLINE S . SEWER LINE - PITS/SUMPS DISTANCE TO NEAREST: SEPTIC TANK AGRICULTURE WELL t "` OTH1 R WELL FOUNDATION _ I >. } TYPE OF WELL PROBLEM AREA CONSTRUCTION-SPECIFiA710NSD1a of Well Casing r INTENDED USE ❑ Manteca Dia. of Well Excavation.} { ❑ Industrial ❑ Open Bottom Tyle of Casing € `" Spec'if'ications a ❑ Gravel Pack ❑ Tracy Type of Grout ❑ DomestclPrivate Q Delta Depth of Grout Seal j ❑ Public Q Other tt �Approx. Depth C] Eastern Surface Seal Installed by 3 El Irrigation H P State Wor Done ` r Repair Work Done ❑ Type of Pump e- G Well Diameter 1 Sealing Material4top 50'1 l Well Destruction - r Depth—I � Filler Material {Below'501 o i available within 200 feet.) j J, •{{ TYPE OF SEPTIC WORK: NEW INSTALLATION Q REPAIR/ADDITION ❑ DESTRUCTION D INo septic system permitted if public sewer is 3Other 111 Installation will serve: Residence, Commercial l Numb living units: Number of bedrooms Water,,able depth �f Characterof soil to a depth of 3 feet: Capacity No. Compartments y SEPTIC TANK ❑ Type/Mfg Methd of Disposal I PKG. TREATMENT PLT. ❑ Property Line Distance to nearest: Well Foundation , t*• Total length/size LEACHING.LINE ❑ No. & L 6th of lines - Property Line 1 f ❑ Distance to nearest: Wells Foundation P rty FILTER BED ,. ' t ,. Number SEEPAGE SEEPAGE PITS ❑ Depth Size— f SUMPS PS to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ f 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 k 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." Contractors 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 compesa- tion laws of California." The applicant must II for all required inspections. Coilgplete drawing on reverse side. 4IK4�Title: Date: Signed s FOR DEPARTMENT USE ONLY �A rea Date r Applicationyy Accepted by Date 4 Date Final Inspection by Pit or Grout Inspection by E Additional Comments: ❑ 5tk, 466 6781 El Lodi 369-3621 ❑ Manteca 823-7104 ❑Tracy 835 6385 - Applicant Return all copies to; Environmental Health Permit/Services 1801 E. Hazelton Ave., P.Q. Box 2008. Stk., CA 95201 ffCK RECEIVED 8YjDATE PERMITNO. FEE AMOUNT DUE AMOUNT REMITTED INFO 5 r �7 s� + EH 13-21 MEV. - EH 11-26