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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 y; , S PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) work herein described.This app made to the application is Application is hereby San Joaquin Local Health District for a permit to construct and/or install the urn County Ord' ante No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin made in compliance with San Joaquin � Local Health District PM Job f � � ��.,.��.-�Z City S'TDL-'ILTa Lot Size Job Address A -� ��A Phone to,` Address Owner's Name 1305 ZS E � lixio n License No.SIZ_L---Phone g Contractor ^t�o= Address l Ti DESTRUCTION LJ NEW WELL ❑ WELL REPLACEMENT ElOTHER -- v� TYPE OF WELL/PUMP: SYSTEM REPAIR ❑ 6 C,/.�r�j PUMP INSTALLATION ❑ DISPOSAL FLO. PROP. LINE DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES---- AGRICULTURE WELL OTHER WELL PITS/SUMPS FOUNDATION _----- INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Open Bottom ❑ Manteca Dia. of Well Excavation E3 Industrial ❑ Tracy Type of Casing � 5 F] ❑ Domestic/Private ❑ Gravel Pack —�"- Delta Depth of Grout Seal Tie-e��n FI Public ❑ Other Surface Seal Installed by I I Irrigation _. t Depth l I Eastern State Work Done_li+G H.P. 9-4et Repair Work Done L1 Type of Pump Sealing Material (top 50') Well Destruction El Well Diameter -- Depth Filler Material (Below 50'1 available within 200 feet.) TYPE OF SEPTIC WORK: NEW INSTALLATION I l REPAIR/ADDITION I 1 DESTRUCTION I 1 (No septic system permitted if public sewer is Installation will serve: Residence Commercial_ Other_---- C Number of living units: Number of bedrooms Water table depth Character of soil to a depth of 3 feet: Capacity___----- No. Compartments , SEPTIC TANK ❑ Type/Mfg Method of Disposal PKG. TREATMENT PLT. ❑ Foundation Property Line Distance to nearest: Well Total length/size LEACHING LINE ❑ No. & Length of lines Foundation Property Line FILTER BED ElDistance to nearest: Well Size — Number SEEPAGE PITS I I Depth Property Line SUMPS Ll Distance to nearest: Well Foundation , DISPOSAL PONDS ❑ I hereb certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, y 11 not rules and regulations of the San Joaquin Local Health District. work for Home owner or licensed agent's signaturesobecome subject following: workman's"I cert ympensation Ithat in the w soof California." Contractor's y 'hu ng'oP sub-contracting ermit is signature employ any person in such manner a 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 compens tion laws of California." ev side. The applicant fo required inspections. Complete drawing 1 K � P Date: Title: Signed X OR PARTMENT USE LY Date Area Application Accepted by Date 2=v r r" Final Inspection by Pit or Grout Inspection by Date--- -- Additional Comments: 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835 Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 9 Applicant 5201 El Stk CK RECEIVED BY DATE PERMIT NO. FEE AMOUNT DUE AMOUNT REMITTED C SH Q INFO -7/1 + EH 13-24(REV.1/e 5) '�- EH 14-26 s►. —