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APPLICATION TOR PERMIT SAN JOAQUIN:LOCAL HEALTH DISTRICT L iN� STOCKTON CA ��•� 1601 E. HAZELTO,N�AVE., � . YC Telephone (209)'466-6781 Tn ..:rA. A PERMIT EXPIRES 1 YEAR FROM'BATE.ISSU,ED .y a- ,• n �t: .3 r. (Completein Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein desations f th application is made in compliance with San Joaquin County Ordinance No.'549 for sewage or No.1862 far welllpump and the Rules and Regulations of the San Joaquin Local Health District. . .. vtfli- -i " City.rd"� CPM 4..v� of Size- _ Job Address - '- _ Y _ Address Phone Owner's Name License No. Phone Contractor's Name f � TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT DESTRUCTION C1 PUMP INSTALLATION SYSTEM REPAIR 0 OTHER ❑ _ SEWER LINES _16Q DISPOSAL FLD. PROP. LINE t DISTANCE TO NEAREST: SEPTIC TAMC PITS/SUMPS FOUNDATION AGRICULTURE WELL OTHER WELL INTENDED USE TYPE OF WELL PROBLEM CONSTRUCTION SPECIFICATIONS +� ❑ Open Bottom ❑ Manteca Type of Casing Dia. of Well Excavation Dia. of Well Casing ❑ Industrial ,al� Specifications � ye✓ I] Domestic/Private AGravel Pack ❑ Tacy Depth of Grout Seal ah Type f Grout Public L1 Other d Delta c 0 F .` ❑ Irrigation Jya�pprox. Depth ED Eastern Surface Seal Installed by d — H P — State Work Done Repair Work Done ❑ Type of Pump y 5eal;ng Material {tap 50'1 I Well Destruction ❑ Well Diameter Depths Filler Material '(Helovv 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION ❑ aNailabfe"withitic n 200 permitted if public sewer is installation will serve: Residence— Commercial_ Other Number of living units: Number of bedrooms Water table depth Character of soil to a depth of 3 feet: �. . Capacity No. Compartments SEPTIC TANK ❑ Type/Mfg '' A Method of Disposal PKG. TREATMENT PLT. ❑ Foundation Property Line ` Distance to nearest: Well Total length/size LEACHING LINE ❑ No. & Length of lines lFoundation Property Line FILTER BED E] Distance to nearest: 'Well Size' Number SEEPAGE PITS ❑ Depth Foundation r I'-"Property Line SUMPS ❑ Distance to nearest: Well s DISPOSAL PONDS ❑ 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. work for Home owner licensed signature certifies following:workman's rtperformance which Psub-contracting shall employ Y personin such manner as to become subject to compensation laws California."Californ aContractr'sh hiring osignature "I certify that in the performance of the work for which this permit is sued, I steal!employ persons subject to workman's campensa- certifies the following: tion jaws of California." The applicant must cal f I requ' d jD41actions. Complete drawing on reverse Ae. k F Title: Date: Signed FO DEPARTMENT USE ONLY Date q 1 C0 A% Area ©� Application Accepted + Date Date " Final Inspection Pit or Grout Inspectio Additional Comments: ��l ii ❑ Stk 466-6781 ❑ Lodi 369-3621 * "-❑ Manteca 823-7144 ❑ Tracy 835-6385 Applicant Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave', P.O. Box 2009,.Stk., CA 95201 CKRECEIVED BY DATE PERMIT"NO. FEE 'AMOUNT DUE AMOUNT REMITTED CASH INFO �� + Ex 13-24 IRE .10/831 d s EH 1426 - -