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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES VYEAR FROM DATE ISSUED. (Complete in Triplicate) Application is he,eby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This application is 1 made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well)purn and the Rules and Regulations of the San Joaquin ! Local Health District..- l City Lot Size JA. PM . Job Address �� • .,.y Phone Owner's Name Address y 01 . �., 1 r •.0 .S'VI ,lp 4`''i'•+ „� _ rr" sus C� ph one Contractor+ Address y License No-. TYPE OF WELLIPUMO iv NEW WELL ❑ WELL REPLACEMENT 0DESTRUCTIUN C PUMP INSTALLATION ❑ 'SYSTEM REPAIR ❑ OTHER ❑. DISTANCE TO NEAREST.:...SEP..T.IC.TANK__, SEWER LINES _ DISPOSAL PLO. PROP, LINE. FOUNDATION s AGRICULTURE WELL OTHER WELL PITS/SUMPS . INTENDED USE ;4YPE-OF WELL F PROBLEM AREA CONSTRUCTION SPECIFICATIONS C] Industrial 0 Op'ri Bottom i❑ Manteca' s'. Dia. of Well Excavation -\61. of Well Casing ❑ Domestic/Private ❑ Gravel Pack X ❑ Tracy Type of Casing Sp cifications W_. .3. z.;. Type of Grout I't Public `0 l I Other ❑ Oilta, ' Depth of Grout Seal el I 1 Irrigation �+APFxax. Depth 1 1 Eastern d Surface Seri installed by 1a 11 ' H.P, _ • State Work one Repair Work Done Type of Pump 'V.-•Well D et?[fL°do'f-i'"•"•'•❑"`"WR_Daineier � Sealing Material (top 50'I E Ll`__ 1 _ � - - Filler Matefiat fB low 50') F� /Dapth isTYPE OF SEPTIC WORK: NEW INSTAL'LATiON{'1;REPAIR/ADDITION , _ IDEST UCTION l l INo septic system permitted if public sewer is _ i fable ithin 2QQ fset.l + •�Installation will serxe;,. Residence—e„CorrTgrcial Other {f%J +* uf'�ri I J. Number of Irving unit : Number of f3Bdroams ' Ch>irecter of soil'to a depth of 3 tees:', ' Water table depth 1 No.Compartments t I I SEPTIC TANK - ❑ Typa e/Mlg., s o Capacity . PICG 6T•�REAf NT PLT.❑ € i j F Meth®sh of Disp I t Distance to nearest: Well Foundation v Property Line t "otal length/size -LEACHING LINE ❑ No,A Length of line _ s 1 PropertyLine f�LTFJi BED � ❑ Distance to nearest dation SEEP.A GE PITS I 1 Depth V _ its � Nutt SUMPS Ll Distance to;nearest: if d -"Property Line S DISPOSAL PONDS r❑'°..•. J I hereby certify that i have prepared this application an8 that the work will be one in accordance with San Joaquin rotln'ordinances,state laws, and ruies�and regulations of the San Joaquin Local Health District. 1 Home owner or licensed agent's-sigitetur¢certifies the following;"I certify that in the performance of the work for which this permit is issued, I shall not 1 employ any person in such manner as to become submit to workman's compensation taws of California."Contractor's hiring or sub contracting signature it certifies the following."I-certify that in the perfom►ar}ce of the work for which this permit is issued,I-shall employ persons subject to workman s compensa- y tion taws of Catifornra")e d 'k i The applicant st au'for aA reltuirsd ins rons::Complete drawing on reverse side. +� v-I Si igned X Title: QAd r Date: - " J %,j k FOR DEPARTMENT USE ONLY .K '- ; Date Area .o,.AWication Accepted by Date Final Inspection by Date I ";.Pit 8r Grout Inspection by .. Addltio_nat Comments: — r O Stk 466-6781- U Lodi 369-3621 ❑ Mantes 823-7104 C] Tracy 835 6385 . Applicant-Return all copies to: Environmental Health Permit/Services 1601 E. Hazefton Ave., P.O. Box 2009, Stk., CA 95201 / ' F FEE AMOUNT OUE AMOUNT REMITTED CK RECEIWED fay PATE PEI rNO ' r INFO CA511 s 10 t Eli t�-�8