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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT ti 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781. ., PERMIT EXPIRES l'YEAR^FROM DATE ISSUED ('Complete in Triplicate) '_ - 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 Ordinance Na.549 far sewage or No.:1862 forwell/pump and the Rules and Regulations of the �s apu�in .11 Local Health District. f W City Lot Size _ PM 7 7 Job Address .�/c�' a'• �r Owner's Name A60 Addre x 4 phonei� �3 _ Phone Contractor's Name ��' �-S eAd' = License No.. ` TYPE OF WELL/PUMP: NEW WELL ❑� �' WELL REPLACEMENT L3DESTRUCTION ❑ -PUMP INSTALLATION ❑ t ,SYSTEM REPAIR ❑ OTHER ❑ DISPOSAL FLD. DISTANCE,-TO NEAREST: SEPTIC TANK- SEWER LINES PROP. LINE E s FOUNDATION ' AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBL-EM•AREA--rbONSTRUCTION SPECIFICATIONS ❑ Open ottomp------OzManteca -- Dia.-of-Well-Excavation _ Dia. of Weil Casing ❑ Industrial SB I I Specifications ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy I Type of Casing T t\'..t - I- I. Type of Grout: Q Other ❑ Delta. -n Depth of Grout Seal yp Cl Public 1 I- r:1. t. 1 f I a ox.-Deptho❑.�Eastern��Surface,5eal_installed by. ❑ Irrigation _ Appr t I �," � State Work Done Repair,Work Done ❑ Type of Pump Y Well ❑ Well Diameter e11 DestlSealing Material (top 50'1 * _Depth Frller Material IBelow 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTIONS avail blelwth ne200 feQ3tted if public sewer is i Installation will serve: Residence— Commercial E O�ther Number of living units: - Number of`hedrooms — pT : y �I I I Water table depth y 0 Character of soil to a depth of 3 feet: I .� I , , �� ' /Zop No. CompartmentsCapacity SEPTIC TANK , Z Method of Disposal ' PKG. TREATMENT PLT. ❑ f Distance to nearest: Well �+4 Foundation,��'0 Property Line 7 S` �� =- oal length/size 2 76 LEACHING LINE [xJ' Na. & Length of lines Tt % ",t FILTER BED El _Distance to nearest: Well -671f FoundationProperty Line�B R i Number 'SEEPAGE PITS ❑ .-Depth Size Property Line BUMPS - ❑ Distance to nearest: tWell Foundation w DISPOSAL PONDS ❑ i t herby 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 District. � " 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, t 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 susbject to workman's compensa= + tion laws of California." The applicant call for all required inspections. Complete drawing Fon rever e side. + 3 . Date:. ! :z: Signed Title: Y' FOR DEPARTMENT,USE ONLY � Date � A Application Accepted by rea- Date Pit or Grout Inspection by Date Final Ins ctio py ke Additional Comments: - ❑ Stk' 466-6781 ❑ Lodi 3W3621 ElManteca 823-7104 ❑ Tracy 835-6385 Applicant- Return ali copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 9WZ1 (3 th FEE GK `° RECEIVED B,Y "y DATE PERMIT NO. INFO AMOUNT DUE AMOUNT REMITTED CASH +EH 13-24(REV.101831 �,_- G p ; /•�!- " - —�LS'� EH 14.28 -