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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT } - 1601 E. HAZELTON AVE., STOCKTON, CA r Telephone (209),466-678'I f PERMIT EXPIRES 1 YEAR FROM gtE ISSUED ".ovO0 pf" -a *' (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District fora ' made in compliance with San Joaquib.County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations permit to construct and/or install the work herein described.:This application is Loco! Health District. yan��._. J � �, / , egulations of the San Joaquin Job Address City Lot Size Owner's Name j /�� /�// / --V PM Address Contractor Phone TYPE OF WELL/PUMP: Address NEW WELL ❑ License Na. Phone Lc5 D fo PUMP INSTALLATION ❑ WELL REPLACEMENT ❑ DESTRUCTION' DISTANCE TON SYSTEM REPAIR El '" ' SEPTIC TAMC.�4 SEWER LINES OTHER ❑ FOU _.DISPOSAL FLD. AGRICULTURE WELL OTHER WELL PROP. LINE INTENDED USE TYPE OF WELL — PITS/SUMPS { ❑ Industrial EM AREA CONSTRUCTION SPECIFICATIONS f ❑ Open Bottum Ll Manteca i C7 Domestic/Private ID Gravel Pack! - of Well Excavation L1 Public Q Tracy T Dia. of Well Casing Other - Type of as E3 Irrigation ❑ 1 ❑ Delta -Depth.df GroutSeal Specifications Repair Work Done 11 T approx. Depth ❑ Eastern Surface Seal Installed by F Tye of Grout YPe of Pump - H.P. Well Destruction ❑ Well Diameter State Work Done w Sealing Material (top 50') Depth TYFiller Material(Below 50') + PE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTIO Installation will serve: Residence (No septic system permitted if public sewer is Commercialavailable within 200 feet.) Number of living units: Other r Number of bedrooms Character of soil to a depth of 3 feet: t SEPTIC TANK ❑ Type/Mfg i Water table depth PKG. TREATMENT PLT. ❑ Capacity—��- No. Compartments Distance to nearest: Well Method of Disposal t Fouirdatian Pro t a perry Line LEACHING LiNE ❑ No. & Length`of lines FILTER BED ❑ Distance to nearest: Well Total length/size i Foundation Property Line SEEPAGE PiTS ❑ Depth SUMPS Size . ❑ Distance to nearest: Number DISPOSAL PONDS Well- Foundation ❑ I �� Property Line I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state la -rules and regulations of the San Joaquin Local Health District. Home owner or licensed agent's signature certifies the following: laws, and " employ any person in such manner as to become subject to workman's compensation laws of California.,,Contractor's hiring or sub-contracting signature g: "f certify that in the performance of the work for which this permit is issued, I shat!not certifies the following:"i certify that in the performance of the work for which this tion laws of Calif permit is issued,1 shall employ g The applicant P Y Persons subject to workman's Com all all r it d inspection Comple a drawing on reverse side.Ign pensa r Title: - f_ =o Date: �J IFDEPARTMENT USE ONLY k Application Accepte by Pit or Grout Inspection by Date— � Area Date - Final Inspection by Additional Comments: —,-1-,7 �L+ �1 DateEl .� Stk 466-6781 ❑ Lodi 369-3521 ❑ 1123-71104 - S-97 F- 11 . Applicant- Return all copies anteca Tfor Environmental Health Permit/Services 7601 E.❑Hazelton gy> 63 gox ��" Y_ �-v tk., CA 95207 FEE AMOUNT AMOUNT DUE C 4 INFO NT REMITTED K _ CASH RECEIVED BY DATE EH 13-24(REV.i i a 51 PERMIT'NO. EH 14-28 � � /� }-�