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APPLICATION FOR �3ERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Applimade intion is hereby compliance with Sanade oJthe oaquinnCounty Ordquin inanccal e No.50.9 for sewagalth District for a eortNo. 1862 forit to cwall and/or install the work herein described. This application 1s Local Health District. Pump and the Rules and Regulations of the San J oaquin Job Address --�2 ) .-- � �— City-'�47 Lot Size �tS PM 312,?— � Owner's Name -/� //.4 z Address 3 ,.�.tVf —— (/ '�✓1 'Phone Contractor Address TYPE OF WELL/PUMP: Or'�Yicense No. -M�� Phone, /v- NEW WELL WELL REPLACEMENT ❑ PUMP INSTALLATION ❑ DESTRUCTION ❑ DISTANCE TO NEAREST: SEPTIC TANK h Lr71 P SYSTEM REPAIR El OTHER ❑ SEWER LINES DISPOSAL FLD. FOUNDATION AGRICULTURE WELL OTHER LINE _ OTHER WELL PITS/SUMPS _ UNTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Irau3twsL.. ❑ Open Bottom ❑ Manteca Dia. of WeN Excavation 56 Domestic/Private\ Gravel Pack ❑ Trac Dia. of Well Casing �L ❑ Public Y Type of Casing_ pVP Specifications ❑ Othe'`❑ Delta Depth of Grout Seal .'S/�� Q ❑ Irrigation ---Approx. Depth Type of Gro t P 9-Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump �- R-.*- State Work Dona t / Well Destruction ❑ Well Diameter !" Sealing MatenT(tap_W1 Depth � _ Filler Material (Below 5010 TYPE PTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No available within Permitted if public sewer is Installation will serve: ce_ Commercial, t ) Other Number of Irving units: _ Num bedrooms Character of soil to a depth of 3 feet: SEPTIC TANK ❑ Type/Mfg Water table depth PKG. TREATMENT PLT. ❑ Capacity No. Compartments y Method of Disposal Distance to nearest: Wall C( Foundation Property Line LEACHING LINE ❑ No. 8 Length of lines FILTER BED 73 Distance to nearest: Well Total length/size Foundation Property Line SEEPAGE PITS ❑ Depth _ SUMPSWall Number ❑ Distance to nearest: Wall Foundation DISPOSAL PONDS ElProperty Line 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Jo rules and regulations of the San Joaquin Local Health District, _ Joaquin county Ordinances, state laws, and Home owner or licensed agent's signature certifies the following: "I certify that in the Performance of the work for which this permit is issued, I sham rot employ any person in such manner as to become subject to workman's compensation laws ofrCamfornia."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, 1 shall employ — iron laws of California." P y Persons subject to workman's co mpensa- The appli an ust cell for al r fired in" ons. o late wing on reverse si,Qe. Signed _ lw q 4 _ 1 MO Wit' / Date: FO O ARTMENT USE ONLY. Application Accepted by ' Area Pit or Grout Inspection by - I�A ata 3� •Final Inspection by Additional Comments; paw CI Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 873-7104 ❑ Tracy 8356385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 85207 FEE AMOUNT DUE INFO AMOAMOUNT REMITTED C.4 RECEIVED BY E PERMIT NO. EH lbw tREy.v e m EH,4za .-7c, ©o C-,� FD:A:T: y s-ro