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APPLICATION, FOR PERMIT SAN JOAQUIN;LOCAL HEALTH -DISTRICT 1601 E. • HAZEL T ON -AVE•, STOCKTON, CA Telephone (209) 466-6781 r PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ' (Complete in Triplicate) • ; 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..C.': . inh Addrace / . / .1 ` /i /Y /f ��rll t� ]0 _('itv r i � e k ...:r l m lCila 1/1�i 1/ / JC! ! PRA yam. hereby eertify ruies and regul Homeowner of arhploy any") i certifies the foil tion laws of Ca The applicant Q Signed Application t I have prepared this application andlthat the work will be done in accordance with San Joaquin county ordinances, state aws, nd is of the San Joaquin Local Health District. nsed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not in such manner as to become subject Ito workman's compensation laws of California." Contractors hiring or sub -contracting SignaT��'uuuuure ig: "I certify that in the performance ofI the work for which this permit is issued, I shall employ persons subject to workman's compersa- call for all required,inspecilons. Co4lete drawing on reverse side. ` �l LTitle: Date: j FOR DEPARTMENT USE ONLY _..f .. �d Data 1Q'�gl Area Pit or Grout inspection by ©ate - Final Inspection by Additional Comments: ❑ Stk 466-6761 ❑ Lodi 36.9-3621 ❑ Manteca 823-7104 ❑ Tracy 835 -6385 - Applicant - Return all copies to: Environmental Health Parmit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 + EH 1324 {REV. 10!93 EH 14-26 Date FEE INFO AMOUNT DUE AMOUNT REMITTED Owner's Name _.� 1+ �T Addrass, ti'• ] .. e - r I Phone JY �7 LT n2W PERMIT"No. {� � � Cont actdt�,larre License No. c7i Phone TYPE OF WELL'JPUMP: k NEW WELL ❑ I WELL REPLACEMENT ❑ DESTRUCTION ❑ gYS PUMP III�STALLATION ❑�,3 EM REPAIR ❑ --- ---- OTHER ❑---- DISTANCE TO NEAREST: SEPTIC TANK SEER -LINES .___.__.__.-- DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELt OTHER WELL PITS/SUMPS j1NTEkDED,{ qSE TYPE OF WELL PRO LEM AREA CONSTRUCTION SPECIFICATIONS �" I ❑ Industrial' ❑ Open Bottom ❑ IV anteca Dia. of Well Excavation ia: of<Weil•Casitjlg LLIDomestic/Pri ate ❑ Gravel Pack ❑ Tici� y Type'of"Casing " " "'"' "` pecifications' :❑ Publici ❑ Other ❑ D Aa Depth of Grout Seal ype of Grout _ C Irrigation RepaiF Doe ElTypelv4Pump _-.-._ Apprpx. Qepth Eastern Surface Seal Installed by �ork 1 H. P. State Work Done Well Destruction ❑_Well Diamete ling Material (top 501 Filier Material {Below 50'} ` -:A TYPE'OF SEPTIC WORK: NE,• QNyTALLAT4OW ❑ E AIR/ADDITION DESTRUCTION ❑ (No septic system permitted if public seweris 'F`,.k available within 200 feet.) 1 Will .} Residenee� Commbrcial Ofher t�lnstallAion serve: . iVumber of 6vi g units: Number of b room C,haracter of s it to a depth of 3 feet: Wafter table depth SEPTIC +ANK ❑ Type/Mfg Capacity fNo?-Gompartments PKG. TREATME'T PLT. ❑ ' Methbd gftDisposal: i Distance to nearest: Well Foundation Property-,L'ne s LEA,CHIIIG LINE I ❑ No, & Length of lines I Total length/Rize 4 FILTER BED ElDistance to hearest: Well Foundation Property Line SEEPAGE PITS i ❑ Depth 1 ize i Number SUMPS c `` �,ti ✓ 1 a �..rni � Distance to nearest: Well Foun at I b 'Property LineI DISPOSAL PONDS ❑ •/ f6 { �; yam. hereby eertify ruies and regul Homeowner of arhploy any") i certifies the foil tion laws of Ca The applicant Q Signed Application t I have prepared this application andlthat the work will be done in accordance with San Joaquin county ordinances, state aws, nd is of the San Joaquin Local Health District. nsed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not in such manner as to become subject Ito workman's compensation laws of California." Contractors hiring or sub -contracting SignaT��'uuuuure ig: "I certify that in the performance ofI the work for which this permit is issued, I shall employ persons subject to workman's compersa- call for all required,inspecilons. Co4lete drawing on reverse side. ` �l LTitle: Date: j FOR DEPARTMENT USE ONLY _..f .. �d Data 1Q'�gl Area Pit or Grout inspection by ©ate - Final Inspection by Additional Comments: ❑ Stk 466-6761 ❑ Lodi 36.9-3621 ❑ Manteca 823-7104 ❑ Tracy 835 -6385 - Applicant - Return all copies to: Environmental Health Parmit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 + EH 1324 {REV. 10!93 EH 14-26 Date FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED 13Y DATE PERMIT"No. 13.13