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Ig 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 No. 549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. {� I m Si -n 4 `'" , 0 70 n rte IA'—�) 9� 7 i 17 , PITA - Owner's Name S�!/i'1�QIFc��` Address ��./_ Phone Contractor Address �� License NG.P_7,1150- Phone._ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ y, •. PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE M FOUNDATION- AGRICULTURE -WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <„y„ ❑ Industrial ❑ Open Bottom,. ❑ Manteca Dia. of Well Excavation -Dia. of'Well Casing ❑ Domestic/ Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 71 Public ❑ Other n Delta- Depth of Grout Seal a Type of Grout _ I Irrigation _.-Approx. Depth I I Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump H. P. State Work Done _ Well Destruction ❑ Well Diameter �� Sealing Material (top 501 t Depth Aller"Material (Below 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION I REPAIR%ADDITION I I DESTRUCTION I 1 INo septic system permitted if public sewer is ✓ available within 200 feet.) Installation -will serve:" Residence r _Commercial. Other:, Number of living units: _A_ Number of be rooms Character of s'oii to -a depth of 3 feet: - _�, ,�. - �” �'" Water table depth 1 SEPTIC TANK pd TypelMfg---61gA C, Ir 4e,Capacity No. Compartments PKG. TREATMENT PLT. ❑Method of Disposal f Distance to nearest: Well �f--Q�— i: o_u 6dation 0 Property _Line., LEACHING LINE l �w No. &Length of -Tota[ lee ngth/siz - FILTER BED to nearest: Well-` Foundation �5 Property Line' SEEPAGE PITS l I Depth Size ' 1 l -'.Number SUMPS ) L1 Distance to nearest: Well Foundation "R' Property Line" ; DISPOSAL PONDS ❑ t _J I nereoy certay that I nave 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, 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." r v The applicant must call for all required, inspections. Complete drawing on reverse side. i } Signed X 14X A 0,0Title: — _ f/1.1r _ Date: to 3 j FOR D RTMENT USE ONLY y y� Application Accepted by/�� ^� Date ^� Area / Pit or Grout Inspection! by Date Final Inspection byr Dat Additional Comments: i ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ► ❑ Tracy 835-6385 s(� Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Haielton Ave., P.O. Box 2009, Stk., CA 95201 \� M=F +.-EH 13-24 (REv"1i K 5) EHE 14-28... FEE INFO APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT CASH 1601 E. HAZEL T ON AVE., STOCKTON, CA DATE PERMIT•NO. Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Ig 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 No. 549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. {� I m Si -n 4 `'" , 0 70 n rte IA'—�) 9� 7 i 17 , PITA - Owner's Name S�!/i'1�QIFc��` Address ��./_ Phone Contractor Address �� License NG.P_7,1150- Phone._ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ y, •. PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE M FOUNDATION- AGRICULTURE -WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <„y„ ❑ Industrial ❑ Open Bottom,. ❑ Manteca Dia. of Well Excavation -Dia. of'Well Casing ❑ Domestic/ Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 71 Public ❑ Other n Delta- Depth of Grout Seal a Type of Grout _ I Irrigation _.-Approx. Depth I I Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump H. P. State Work Done _ Well Destruction ❑ Well Diameter �� Sealing Material (top 501 t Depth Aller"Material (Below 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION I REPAIR%ADDITION I I DESTRUCTION I 1 INo septic system permitted if public sewer is ✓ available within 200 feet.) Installation -will serve:" Residence r _Commercial. Other:, Number of living units: _A_ Number of be rooms Character of s'oii to -a depth of 3 feet: - _�, ,�. - �” �'" Water table depth 1 SEPTIC TANK pd TypelMfg---61gA C, Ir 4e,Capacity No. Compartments PKG. TREATMENT PLT. ❑Method of Disposal f Distance to nearest: Well �f--Q�— i: o_u 6dation 0 Property _Line., LEACHING LINE l �w No. &Length of -Tota[ lee ngth/siz - FILTER BED to nearest: Well-` Foundation �5 Property Line' SEEPAGE PITS l I Depth Size ' 1 l -'.Number SUMPS ) L1 Distance to nearest: Well Foundation "R' Property Line" ; DISPOSAL PONDS ❑ t _J I nereoy certay that I nave 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, 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." r v The applicant must call for all required, inspections. Complete drawing on reverse side. i } Signed X 14X A 0,0Title: — _ f/1.1r _ Date: to 3 j FOR D RTMENT USE ONLY y y� Application Accepted by/�� ^� Date ^� Area / Pit or Grout Inspection! by Date Final Inspection byr Dat Additional Comments: i ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ► ❑ Tracy 835-6385 s(� Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Haielton Ave., P.O. Box 2009, Stk., CA 95201 \� M=F +.-EH 13-24 (REv"1i K 5) EHE 14-28... FEE INFO AMOUNT DUE AMOUNT REMITTED CASH ,1 RECEIVED BY DATE PERMIT•NO.