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E APPLICATION. ..FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE.,.ySTOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRESI YEAR FROM DATE ISSUED .,, . ,q ,. ? GOrnplete in Triplicate) , __: ,-1 Trip _ •.. � ,. . Application is hereby made to the San Joaquin Local Health Districtfor 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.' x fJob Address Lot+Size :.n•. , _ Owner's Name ✓f"1 _. : - .,: ... C�/ M d e§s-" N� 1L Phone 1 r6 � Contractor Address License No. - Phone_ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 0' DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM`REPAIR ❑ J s . ` "`,. :OTHER`❑ DISTANCE TO NEARE TANK LINES ' _ _ -- - _ _ DISPOSAL FLD..' PROP,_LINE. ." .'- FOUNDATION TURF WELL `"O " `r� SELL u~"PITS/SUMPS,_ INTENDED USE TYPE OF WELL PROBLEM AREA RU IFICATIONS ❑,Industrial ❑ Open Bottom I] Ma Dia. of Well Excavation Dia. of Well Casing E-1 Domestic/ ❑ Gravel Pack Tracy Type of Casing ications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal " '` ` Type of Gro ❑ Irrigation pprox. Depth ' ❑ Eastern Surface Seal Installed by �� x Repair Work Done Type of Pump H.p t t State Work Done 9� Well Des n ❑ Well Diameter Sealing Material (top 50') r Depth ° .Filler Material (Below 501 a' TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ ;REPAIR/ADDITION ❑, DESTRUCTION o septic system permitted if public sewer is �J -mom` a available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms ; Character of soil to a depth of 3 feet: L Water table depth SEPTIC(TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ t - ; Method'of Disposal Distance to nearest:• Well s Foundation'—~ Property Liner LEACHING LINE ❑❑ ,. No. & Length of lines j t - Total length/size t FILTER BED I -•-'"-..tion--• --„�- _ro Distance to nearest: Well Foundation Property`Line SEEPAGE PITS ❑ Depth Size r k SUMPS -Distance to nearest: Well - Foundation NumberProperty Line DISPOSAL PONDS ❑ �• I heretiy,certify that,(`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.I,lealth District. Home owner or licensed agent's signature certifies the following- s "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- 4,i-tion laws of.California. The applicant must caall,re wired inspections. C pl a drawing on reverse side. a� }S gned t w — ,� Title:k 5 L � Date: - - - FOR DEPARTMENT USE ONLY s Application Accepted by Date ., Area _J Pit Pit or Grout Inspection by /ate- Final Inspecti Pn by f Date Additional Comments: 4� s ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca .82 - 1 ❑ T cy ,835-6385 . ice._ ; Applicant Return all copies to: Environmental Health Permit/Services 1601E Hazelton Ave., P.O.,Box 2009, Stk., CA 9 1 C r • EY AMOUNT REMITTED NFOO AMOUNT DUE M CK RECEIVED BY, PATE PERMIT' + EH 124(REV.1/N 5) C� l•��b - - p �� EH 14.4.28 �(�� ! J r• � 3 �- iV rIDfiV►GUv