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I � r APPLICATION FOR PERMIT SAN.JOAQUIN LOCALYHEALTH DISTRICT 1501 E. HAZEL!ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Application is hereb ► '` (Complete in Triplicate) Y made to the San Joaquin Local Heakh District fora} made in compliance with San Joaquin County r w Local Health District. �' `'' T3 tY Ordinance No Permit to construct and/or install the wok herein described. This application is �:. 549 far sewage or Na. 1862 for well/pump and the Ryles and R egulations of the San Joaquin Job Address r `City Lot S Owner's Name " ize j P .., ✓ai. • .. { - M Address Contractor Q' S J`y 'Phone' _ TYPE OF WELL/PUMP: ddress Z/ NEW WELL ❑ WELL REPLACEMENT ❑ License No. PUMP INSTALLATION Phone DISTANCE TO NEAREST: SEPTIC TANK DESTRUCTION ❑ SYSTEM REPAIR ❑ F SEWER LINES OTHER ❑ FOUNDATION AGRICULTURE WELL DISPOSAL FLD. INTENDED USE OTHER WELL ~ PROP. LINE l TYPE OF WELL PROBLEM AREA �— PITS/SUMPS �"�"❑ Iridustriai LL ❑ Open Bottom "-� CONSTRUCTION SPECIFICATIONS M Domestic/Private EJ Manteca �Dia..of Well Excavation ❑ Gravel Pack Dia.. Dia. of Well Casing ❑ Public ❑ Other Type of Casing ❑ Irrigation ❑ Delta Depth of Grout Seal Specifications R Repair Work Done Approx. Depth Q Eastern Surface Seal Installed by TYPe of Grout [ ❑ —Type of Pump Well Destruction ❑ Well Diameter H P. Sealing Material (top 50') State Work Done r Depth Filler Material (Below 50'p I JrTYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ t � ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is Installation will serve: Residence i �• Commercial— Other available within 200 feet.) 1 Number of living units: , r Number of bedrooms Character of soil to a depth of 3 feet: M SEPTIC TANK 11Type/Mfg Water table depth PKG. TREATMENT PLT. ❑ Capacity_ .No. Compartments I Distance to nearest: WellFoundation Method of Disposal I 6 �— Property Line c i LEACHING LINE ❑ No. & Length of lines.. • Y FILTER BED ❑ Distance to nearest: Well �i Total length/size Foun dation 3--:--�• � Property Line ` �,y.,•� , SEEPAGE PITS D .` Q epth- � '^� � � 1 � SUMPS Number ; ❑ Distance to neares;: Well f i DISPOSAL PONDS ❑ +J s. f Foundation property Line I hereby certify that I have prepared this application and'that theworkiwill be done in accordance with rules and regulations of the San Joaquin Local Health District. ; 'San Joaquin county ordinances, state laws, and Home owner or licensed agents signature certifies the following employ any person in such manner as to become subject to Workman's compensation laws of California."Contractor's hiring or sub contracting signatn t certify that:ln the Performance oFthe work for which this - certifies the following:-'I-ce permit is issued, 1 shall not tion laws of California." that in the Perfarmance'oftheworK'for-whichtFiis pefmit is issued;I sFiall em'lo The applicant ust c II f alt r u' inspections. Com late�draing omreverse de - p y Persons sutijecf to workman's compensa- p = _ 3 —Sig`ned- "Title: _ t Y Date FOR DEPARTME T USE ONLY Application Accepted by- t Date 44 Pit or Grout Inspection bArea y } Date s. t Final Inspection by 2 ADatedditional Comments: _ -n , 466-6781 o Lodi 369-3621 n Manteca 823x104y ❑:Trac 8355-6385 Applicant- Return all copies to: Environmental Health Permit/Servicegf1601 E. Hazelton Ave., P.O. Box 2009,'Stk., CA 95201 # FEE AM _QUNT DUE AMOUNT REMITTED CK y —" INFO x k CASH- RECEIVED BY �DA�T�E-., •PERU17Np, $ j 1324iREV,1i95f 414-26