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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT_: 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466 67$1 PERMIT EXPIRES 1-YEAR FROM DATE ISSUED ?licate in (Complete Tri p bra`i?S S E_SCA-r 0 E p p ,J : 2�2 s -r � o Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is made in compliance with San Joaquin un Ordinance NogA9 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local earth Distril,D �r Job Address CQ I' City C Lot Size PM 00 Owner's Name.. Address / / 7 / � v P Phone Cpntracfor' '' ) 55 Litense No. ^ - Phone 7 TYPE OF WELL/PUMP: -NEW WELL 91N WELL REPLACEMENT ❑ DESTRUCTION ❑ "' ` " PUMP INSTALLAT ON - 'SYSTEM REPAIR ❑ """ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD.�&�ROP. LINE i 6 FOUNDATION ._ AGRICULTURE WELL THER WELL .PITS/SUMPS ` INTENDED USE TYPE'OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS � ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing omestic/Private [&Gravel Pack ❑ Tracy Type of Casing - Specifications fl Public I Other Cl Delta Depth of Grout Seal�w � � Type of Grout D (� f 1,1 irrigation _Approx. De h i I Eastern Surf Seal Installed by - Repair Work Done Type of Pump H.P.3 ]- -- State Work Done Well Destruction ❑. Well Diameter Sealing Material (top 501 1 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION l l REPAIRIADDITION l I DESTRUCTION I I INo septic system permitted if public sewer is available within 200 feet.l installation will serve: Residence_ Commercial__._ Other \> Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth ' i SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property.Line is LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Linej 3 SEEPAGE PITS i I Depth Size Number ry ' 1 SUMPS ❑ Distance to nearest: Well Foundation Property Line j DISPOSAL PONDS ❑ i 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 Di1trict. 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 became 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 employ persons subject to workman's compensa- tion laws of California." The applicant u t ca or all required inspections. Complete drring on averse side. / Signed X Title: , ! Date: �F FOR DEPARTMENT USE ONLY I / Application Accepted by Date I k� Area i J Pit or Grout Inspection by Date //43 Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 523-7104 © Tracy' 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE MOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'Nal. INFO CASH_ +.EH 13-24 IAEV.F/H 51 rO J •U� yr/ ,V.- f rI A $ l7[/ . {{{ ! EH 14-2e .,�'- :_. '�t1 .�- .. ...r'..