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� h APPLICATION FOR PERMIT D � JOAQUIN LOCAL HEALTH DI STRIC s' „ . . SAN 6 CA 1601 E. HAZE' ON AVE., STOCKTON, JUN[ I Telephone (209) 466-6781 OMEN-FAL H . PERMIT EXPIRES 1'YEAR FROM DATE 1SSft�'Q��MrT'/$ER E4L� � (Complete in Triplicate) . This lication is work to the San Joaquin Local Health District for a permit o 18fi2 for construct dpump and the Rules and iRegulations of the San Joaquin i Application is hereby ma /or install the de I made in compliance with San Joaquin County Ordinance No.549 for sewage or Local Health District. l ` A 1 Lot Size City ! Job Address 5 36 Phone Address Owner's Name • 1 +7 27 r. /`�-L.icense No. r Phone3 I Address DES7RUCT10N ❑ Contract WELL REPLACEMENT ❑ NEW WELL OTHER ❑ # TYPE OF WELLIPU P: SYSTEM REPAIR ❑ ,�9�` PUMP INSTALLATION 0 DISPOSAL FLD. PROP. LINE DISTANCE TO NEAREST: SEPTIC TANK �ttt�'; SEWER LINESL PITSISUMPS ��y� AGRICULTURE WELL � OTHER WEL4 [ FOUNDATION TYPE OF OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATION Dia. of Weli Casill k INTENDED USE — �� Dia. of Well Excavation ❑ Industrial pen Bottom ❑ Manteca M Specifications ❑ Gravel Pack ❑ Tracy Type of Casing DomesticlPrivate Type of Grout — f! Other C 1 Delta Depth of Grout Seal g i I'I Public Surface Seal Installed by y ( I Irrigation APprox. Depth i I Eastern State Work Done— '.: H.P. I Repair Work li ❑ Type of Pump Well Destruction ❑ Well Diameter Sealing Material l s Depth Fillet Mater Below 50'1 f`1 - �._.. V available within 200 feet.( TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION ( I DESTRUCTION 4 I (No septic system permitted if pubic sewer is f Commercial _Other Installation will serve: Residence jNumber of bedrooms { s l Number of living units: Water table depth Character of soil to a depth of 3 feet: Capacity No. Compartments r SEPTIC TANK ❑ Type/Mfg Method of Disposal �A { PKG. TREATMENT PLT. ❑ Foundation Property Line Distance to.nearest: Well a II ` y Total lengthlsize LEACHING LINE ❑ No. & Length of lihes Foundation Property Line FILTER SED L3Distance to nearest: Well I i Depth Size Number ;r ' � SEEPAGE PITS Foundation Property Line SUMPS Cl Distance to,nearest: Well DISPOSAL PONDS ❑ j I 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 wl shall not rules and regulations of the San•Joaquin Local Health District.g .a ,o Home owner of licensed agent's signatufe certifies the to become subject following: wing: "I c s�compensation lthat in the aws of Califoirnil" Contract yr hiring hich 1 orr sub-cos permit isntract nglsignature 1 employ any person in such ma ersons subject to workman's�compensa certifies the following:•'I certify that in the performance of the work for which this permit is issued, I hall employ p �) tion laws of California." . Complete drawing on reverse side. r�'' S The applicant us call for all r quirod in Date: Title: j Signed X / i r, FOR DEPARTMENT USE ONLY Area >i Application Accepted by Date I — Final Ins action by � Date ^ Pit of Grout Inspection by ] ; , ` - r { ` i Additional Comments: { ❑ Stk 466-6781 ❑ Lodi 369-362} ❑ M tete 823 7104 d Tracy 835- m 35 ''. CA-95201--.- � —1 4 Applicant Return all copies.to: Environmental-Health.Permit/Services,1601..E..Hazelton.Ave., P:O.•Box 2009,_Stk.,• »' PERMIT MOUNT N4. AMOUNT REMITTED ASR RECEIVED BY DATE FEE p0UN7 DUE INFO /H51 4T 8 r EH 1324'IRSV r y l'