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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 'f YEAR FROM DATE ISSUED ��-`0� f�T� �—�-VEI - (Completeln iplicate) I 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 County Or`di ance No. 549 for sewage or No. 1862 for well/pum and t e ule�ps and Regul ions o the San Joaquin Local Health District. �� /U/v ��i�J�G '� T `�'�!��J;La5 #'4s Jab Addresso itY \ Lot Size PM OwnersName tldress _, �etJ Phone Contractor L`[! /S! ddres License No.� �Phonef TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL. FLO. PROP. LINE E FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 0 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing c O Domestic/Private Ll Gravel Pack ❑ Tracy Type of Casing Specifications ! e of Grout k"= l'il Public ❑ Other ❑ Delta Depth of Grout Seal Type � '� 11 Irrigation -__..Approx. Depth l I Eastern Surface Seal installed by - �•� Repair Work Done ❑ ' Type of Pum _rte H.P. State Work Done _ �p 1 i zr Well Destruction Well Diameter' � Sealing Material (top 50') t itf dA w r Depth - Filler Material (Below 50') F TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I 1 iNa septic system permitted if public sewer is ` ! available within 200 feet.) € Installatiotpwill serve: Residence Commercial— Other f ( Number of living:units: Number of bedrooms Character�j soil to a depth of 3 feet: Water table depth t i SEPTIC T NA K ❑ Type/Mfg Capacity No. Compartments I i PKC. TREA�MJ NT PLT. C7 Method of Disposal t Distance to nearest: Well Foundation Property Line r i r LEACHING LINE ❑ No. & Length of fines-,T 1- Total lengthlsize FILTER BEP 1 C7 Distance to�isare�st:{ry tW{ell� __ Foundation Property Line !�zp ��r�t�y{ �1' 'r SEEPAGE PITS I 1 Depth I � Srze Number SUMPS `t ❑""Distance to-nearest.—Well _ Foundation _ _ _P_roperty Line DISPOSAL P614DS ❑ I hereby certify that I have prepared this application and',lhal,tFie� ork will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Loca Healtfv DisfFict i\ 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 perso6irrsuch•manner-a"d..becom@-subject 10_WQEkman's compensation l'aw_s..of-California.-" Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work fq�_r'w�iicFi tFfis permit is issued, I shall employ persons subject to workman's compensa tion laws of California." The applican o'Vail'fet � ions. Complete drawing on reve se side. 3 f ` t � Signd X Title: Date- 4 w 1 R DEPARTMENT USE O Y Application Acceprad by ` t` Date -�Op Area / j Pit or Grout Inspection by D- I Final Inspection by522 Date �T_`" ( Additional Comments: { O Stk 466-6761 ❑ Lodi 369-3621 LI Manteca 823-7104 L1 Tracy 835-6385 Applicant - Retur all copies to: Environmerblialal Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 1 { 1 r_E 1A. t � - t IFEENFO dAMOUNT l]UEAMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. I I `'7` G 14-24(REV.i/»51 "- a,w------i �/ , '-4 5 I EH 1026 � �.•��_..-__ Ek •. �g