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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE'LTON AVE., STOCKTON, CA Telephone (209) 456-6781 PERMIT EXPIRES 1-YEAR FROM DATE ISSUED (Complete in Triplicate) !;cation is un Ordinance Health District for sewage r t t con1B6for welt/pump and the Rules and Regulations of the San Joaquin Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This app made in compliance with San Joaquin C tY Local Health District. PM !] {� C4City ' -1 Lot Size Job Address z Phone Owner shame -��- " � �_ j { ` M :� CTION ❑ Address_.__ ' � f "eb1111a'cfor"'- or WELL REPLACEMENT ❑ DEQ RU J NEW'WELL ❑ ' l° OCHER-❑ TYPE OF WELL/PUMP: SYSTEM REPAIR L1 PUMP INSTALLATION 1-1 's DISPOSAL FL s ;_�i�•PROP' UNE ` SEWER LINES �� DISTANCE TO NEAREST: SEPTIC TANK OTHER WELL `• PITSlSUMPS �- FOUNDATION 1— AGRICULTURE WELL ` INTENDED USE TYPE OF WELL PROBLEM CONSTRUCTION.SPECIFICATION Dia of Well Casing V ❑ Open Bottom ❑ Manteca Dia. of Weil Excavation ❑ Industrial Specifications - ❑ Gravel Pack ❑ Tracy Type of Casing Type of Grout _ -❑ Domestic/Private t Cl f7 Delta Depth o; f Grout-Seal n Public Other ` _Approx. Depth I I Eastern Surface Seal installed by I I Irrigation -- H P State• ork.Lt nem ru F Repair Work Done ❑ Type of Pump �. � ^' a1 Sealing Mat �rial (top,50? p Well Destruction ❑ Well Diameter ,rr i Depth Filler.M tehal i6�low 501_ i erntitted if public sewer Is 4 available with. '00 feet.) TYPE OF SEPTIC WORK: NEW INSTALLATION C REPAIR/AD,DITION i 3 DESTRUCTION I I INo sap`c s qF( P M A°;d 7 ! Other t !CommercialResidence r, Installation will serve ' 67 Number of living units: — Number of bedrooms l Water tiblbi lgPth ' Character of soil to a depth of 3 feet: C4 No. Comp irtments a -- r fl Type/ ` E w -», i' ; i":�. SEPTIC TANK 6 Method ofCisposal'" PKG. TREATMENT PLT. ❑ Foundaiit, r 1 ---.Property.Line ., ! Distance to nearest: p Well , ,r t } t 6 . Total legthll l LEACHING LINE -No. & Length of lines =-+ � p�perty Lin- e { FILTER BED LINE., Distance to nearest: Well Foundat+onr ! 1, • Size Number. { SEEPAGE PITS ti Depth ii Well Found�tian Property Line 7 — E'. SUMP5 L� Distance to°nearest. �y ._-,. a DISPOSAL PONDS ❑ I hereby certify that l have prepared this'app lication and that the work will be done in.-accordance with San Joaqu ounty ordinank�r s, state lavvs,`and rules and regulations of the San Joaqul`n Local Health District.g �`* _ �`"Y ) Home owner or licensed agent's signature certifies the subject wlorkman'sw: certify thensation l a in the s of Calif 'rona.g Contractos h ri g1 orpsub�c�ont aclinglsignlatu�e employ any person in such manner as to becomes 1 certifies the following: "I certify that i�the performance of the work for which this permit Is issued, I shall employ arsons subject to wt an's compensa tion laws of California." ' i F 1 . The applicant must call or all quired inspections- Date,Complete drawing on reverse side. {� pate: Signe8 X FI'DE TMENT US ON6x. Date Area ` Applicatiolf4cepted byT ` Date''' 7 ' +--' ¢A'> Date.^�� Final Inspection by >rr P' r Grout Inspection by 7 +� ,i l Additional Comments: .3 ❑ Stk 466-6781 ❑ Lodi 369 3621 ❑ Manteca 823 7104 ❑ Tracy 835-6385 Applicant - Return all copies to:"Envirdn mental Heal�,0ermit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk"';�CA 95201 ; CIC RECEIVED BV DATE PERMIT NO. FEEAMOUNTbUE'.w AMOUNT REMITTED CASH INFO r +.EH 13-24 IREY.t/n 51 ,Q 1•' _ EH 14-26