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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT z le�vt— f. I- 1601E. HAZEL T ON AVE., STOCKTON, CA L,/Ie �1 1, Telephone (209) 466-6781 PERMIT EXPIRES I"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 s 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. t 1 I a � Job Address q afzi/ y 1 City s p Lot Size PM Owner's Nam �� Address_ I ' Phone t Contractor A - �Add TYPE OF WELL UMP: License No. _Phone NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ DISTANCE TO NEAREST: SEPTIC TANK OTHER ❑ SEWER LINES �.�_- DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Apia. of Well Excavation ❑ Domestic/Private ❑ Gravel Pack _ Dia. of Well Casing D Tracy Type of Casing' M P"bl'c f-! Other 0 Delta Specifications Depth of Grout Seal I I Irrigation Type of Grout Approx. Depth I I Eastern — Repair Work Done ❑ Type of Pump�- HSurface Seal Installed by .P. , Wel! Destruction ❑ Well Diameter State Work Done Sealing Material (tap 50') Depth Filler Material (Below 50') TYPE OF SEPTIC WORK; NEW INSTALLATION I:i P } F—, � r�f ; T, ( o p c system permitted if public sewer is Installation will serve: Residenc RMS 1 ie within 200 feet.] Commercia Number of living units: Number of bedrooms ~�~ Character of soil to a depth of 3 feet -P—erT I may have expired without SEPTIC TANKType/Mfater table depth ❑ g1:, PKG. TREATMENT PLT. EJ + )ft �m �r—!-- o- Compartments by Environmental Health DIVISiONethod of Disposal Distance to nearest:. Well' Foundation Property Line LEACHING LINE ❑ No. & Length of lines FILTER BEDTotal length"/size ❑ Distance to nearest: Wel! Foundation Property Line SEEPAGE PITS 11 Depth i l Size SUMPS Ll Distance to nearest: Well Number DISPOSAL PONDS ❑ # Foundation Property Line 1 hereby 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: "1 certify that in the performance of the work for which this r employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signanot ture certifies the fallowing: '9 certify that in the performance of the work for which this permit is issued,.,f_shalGemploy pdrsorrs subject to workman's compensa- tion-laws-of California," The applicant must call fo a u'ed ins _ J 3 pecti s. Complete drawing on r verse sides Signed X Title: /I Date: eel FOR DEPARTMENT USE ONLY ) Application Accepted by 1 //0 0 �d6 2 . ;�wllol yV„ �S Date �lJArePit or Grout Inspec " (-+��t na-I. /I4m Date inal Insp ction by - Additional Comments: � Date ❑ Stk 466-6781 ❑ Lodi 369-3621.1 El Manteca 823-7104 --T12 •)11� Applicant - Return all copies to: Environmental Health Permit/Services 1601 E.❑Hazel on Av e,-P.O. Box 2009, Stk., CA 45201 FEE AMOUNT DUE CK INFO AMOUNT REMITTED RECEIVED BY H DATE PERMIT'NO. + EH 18-2 tREV,tis51 � l EH 11-28 - f d-�- /moi _ f/ F