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+�d1i APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT t 1601 E. HAZELTI ON AVE., STOCKTON, CA Telephone (209) 466-6781 �, ( � PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete In Triplicate) construt and/or install the work Application is hereby made to the San Joaquin Local calnce Health istrict for sewage for a mit tor o 1862 forcwherein application ellipump and the Rules andR gh Regulations of e SanJoaquin made in compliance with San Joaquin county Local Health Dish r_.� Size . $ PM _ City Job Address i PhorlgllL-4- -�Address / Owner's Name Q� a(�( J G rQr I License Ivo. OQ honaJ Contractor t rasa WELL REPLAGEMENT ❑ DESTRUCTION ❑ TYPE OF W€LLIPUMP: NEW WELL OTHER ❑ ' / PUMP INSTALLATIO SYSTEM REPAIR ❑ -i -� _� DISPOSAL FLD. PROP. LINE C DISTANCE TO NEAREST: SEPTIC TANK j SEWER LINES OT ER WELL OTSISUMPS FOUNDATION AGRICULTURE WELL INTENDED U5€ TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICAT NS � �— Dia. of Well Casing ❑ Industrial ❑ Open Bottom An ❑ Manteca Dia. of Well Excavation :Specifications Type of Casing F / Domestic/Private ❑ Gravel Pack ❑ Tracy pe of Groulli_ , "' F1 Other F7 Delia Depth of Grout Seal12 P Public Surface Seal Installed by I I Irrigation - -Approx. Depth 4 I Eastern State Work Done— H.PMr-fl�rn'�Il rRepair Work Done ❑ Type of Pump , a nflop 5Well Destruction ❑ Well Diameter _ Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I l REP IR/A)7DITION I I DEST CTION l I available-within200 feet.) if public sewer is n � er f � Installation will serve: Residence— Commercial � -- Number of living units: Number of bedrooms Water table depth l Character of soil to a depth of 3 feet: Capacity No. Compartments SEPTIC TANK ❑ Type/Mfg Method of Disposal PKG. TREATMENT PLT. ❑ Property.Line i Distance to nearest: Well Fo ndation 'r 1 LEACHING LINE ❑ No. & Length of lines Total lengthlsize 1 FILTER BED ❑ Distance to nearest: W Foundati Property Line SEEPAGE PITS I i Depth Size Number k Foundation Property Line f SUMPS Cl Distance to nearas: Well 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, an rules and regulations of he San Joaquin Local Health O'Wrict. 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." 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 must call for all required inspections. Complete drawing on reverse side. r � Date- OR Signed X OR DEPARTMENT USE ONLY t Date `c+ Area y Application Accepted by Pit or rout Inspection by Date Final Inspection b� /�/ ' _ Date G ( Additional Comments: _S ❑ Stk 466-6781 ❑ Lodi 369 3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 r FEE MOUNT DUE AMOUNT REMITTED RECEIVED BY K DATE PERMIT NO. INF ^�`� l� ( A �Q d ♦.-EH 13-21(REV.i n sY l C),�.V �-+ 1 L/ J'11l.j 1 ` r�• F ' 4 A. EH 14-2B -