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IT ID APPLICATION FOR PERM SAN JOA(lUIN LOCAL'HEALTH DISTRICT ' 1601 E. HAZEL i ON AVE., STOCKTON, CA i Telephone (209):466-6781 YEAR FROM DATE ISSUED PERMIT EXPIRES 1 i (Complete in Triplicate) ll the work herein described. This application is Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or insta ance No.549 for sewage or No. 1662 for well/pump and the Rules and Regula made in compliance with San Joaquin County or 11 tions of the San Joaquin Local Health District. PM City S Lot Size 6- Job Address I `��4L �� Phone v Address �( Owner's Name ,,�r 5133 Q 1 / 5 r 9� j License No. --o�UPhane I�, 1''G ekddress Contractor U ! WELL REPLAC MENT 0, DESTRUCTION ❑ TYPE OF WELL/PUMP:" � NEW WELL ❑ OTHER ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ SEWER LINES _�-- DISPOSAL_FLD. PROP. LINE DISTANCE TO NEAREST: SEPTIC TANK —_�- OTHER WELL PITS/SUMPS FOLfNDATION �� AGRICULTURE WELL INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia of Well Casing ❑ Industrial ❑ dpen Bottom ❑"Manteca Ria. of We11"Excavation - Specifications f ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing _ \ Depth of Grout Seal Type of Grout Cl Other C I Delta _ public Surface Seal Installed by ! IRI irrigation :.Appro�Ptf? l 1 Eastern Repair Work Done ❑ Typle of Pump : H.P. r State Work Done Sealing Material {top 50'1 Well Destruction ❑ -We I Diameter Filler Material {Below 50') 1. Depth TYPE OF SEPTIC WORK: NEW INSTALLATIO fiEPAIRIADDITION DESTRUCTION I 1 INo septic system permitted it public sewer is t available within 200 feet.) I�I .� I Installation will serve: Rejlence X Commercial_ Other �� 7 Number of living units: Number of bedroorps — - water table depth ` Character of soil to a depth of 3 feet: � No. Compartments r SEPTIC TANK + [-IType/Mfg Capacity i Method of Disposal I PKG• TREATMENT PLT. D r r ' Distance to nearest: Well "�� Foundation Property Line��- l i �tal length/size k LEACHING LINT 1 " No. & Length of linesi FILTER BED [� Distance to nearest: Well � Foundation� b Property Line �d i t /1 Y] Silo umber SEEPAGE PITS l y .Depth CC ' Foundation 9 Property Line =0. j SUMPS Ll I Distance to nearest: Well L 77� DISPOSAL PONDS ❑ 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, aril rules and regulations of the San Joaquin Local Health District. r is signature certifies the following-"I certify that in-the.perforniance of.the work for which o hich thispermit cont act ngs Ihal) t Home owner or licensed agen g { employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's certifies the following; I certify that in the.perforrnance of the work for which Ah permit is issued, Ishak employ persons subject to workman's compensa j tion laws of California." t The applicant m st call for'�II requir ctions Complete drawing on reverse side i J III Date: itle: Sig •F EPARTMENT-USE ONLY -^" 7 E �� 'aC7 Area Date Application Accepted by 7 Final Inspection by l Date Pit'or Grout Inspection by Date rr 1 n►� ✓T. a ... —R�-_..... Additional Comments: - '835-6385 ❑ Stk=466-fi781" O�-odi—369-3621 ❑ Manteca`-823-7104 W ❑ Tracy "' es to: Environmental Health Permit/Services 1601 E''Hazelton Ave,,,P. . Box 2009, Sik.,:CA 95201 Applicant- Return all copi �[\ l ' ` O� 1.: �\' CK DATE FEE AMOUNT DUE AMOUNT REMITTED ASH RECEIVED BY PERMIT Nyo'.� i INF iF C�j -EH 13-24MEV.1/Nb) it) -0 EH 14.2e .111