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APPLICATION FOR PERMIT I SAN ,JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA � Telephone (209) 466-6781 PERMIT EXPIRES 1"YEAR FROM DATti ISSUED (Complete in Triplicate) application is Hance No.District for sewage or No. 18&2 for well/ pump and the Rules and Regulations of the San Joaquin Application is hereby made to the San Joaquin di al Health District for a per to construct and/or install the work herein described. This PP {1 made in compliance with San Joaquin county Local Health District. PM �— ` ,� City r Lot Size ,261 u r T 1' (�sr sr3s r � Job Address Y ! P.6` � Phone jay f Adds i Owner's Name �r►+ee resPhone C 0="& ewjd P L icense.No. u, ddress ' Q DESTRUCTION ❑ Contractor WELL REPLACEMENT ❑ OTHER �Sd i'I NEW WELL ❑ J TYPE OF WELLIPUMP: SYSTEM REPAIR EJ PUMP INSTALLATION ❑ DISPOSAL FLD. PROP. LINE j2/r✓� SEWER LINES �--- PITS/SUMPS I DISTANCE TO NEAREST: 5fP71C TANK -----" AGRICULTURE WELL OTHER WI LL FOUNDATION —� INTENDED USE TYPE OF WELL PROSL� EM AREA CONSTRUCTION SPECIFICATIONS pia. of Well Casing ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Specifications ❑ industrial ;" Tracy Type of Casing rT C rt ❑ Domestic/Private ❑ Grave! Flack �c� ,p Type of Grout O-- W'OtherS#X4Wh' ❑ Delta Depth of Grout Seal T FI Public Surface Seal Installed by 4 I I irrigation n L49APProx; Depth l I Eastern State Work Done Sdr'� Type of Pump �— H P' f" Repair Work Done ❑ YP & Sealing Material (top 50'1 ertCar� C p Well Destruction ❑ Well Diameter Filler Material (Below 50') � Depth ermined if public sewer is C] available within 200 feet.) TYPE OF SEPTIC WORK: NEW.INS ALLATION {:I REPg1R1ADDl... lwl DESTRUCTION 4 I (No septic system Commercial Other�� Installation will serve: Residence l! Number of living units: Number of bedrooms Water table depth Character of soil to a depth of 3 feet: Capacity� No. Compartments SEPTIC TANK ❑ Type IMI!g Method of Disposal PKG. TREATMENT PLT. ❑ x Foundation Property.Line Distance to nearest: Well �— n Total lengthlsize l LEACHING LINE ❑ No. & Length of lines Foundation property Line FILTER BED ❑ Distance to nearest: Well ' r : Number I l Depth Size SEEPAGE PITS Foundation Property Line { FI Distance to neatest: Well C SUMPS ` DISPOSAL PONDS ❑ 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, an tIs issued, I shall not rules and regulations of the San Joaquin Local Health Di$trict. that in the Home owner or Licensed agent'irsignature f n torbecome sub a folio work"I c coympensation lawsofperformance a." Contractor's which E g op sub-cont act ng signature l employ any person in such man I certifies the following: "I certify that in the performance of the work for which this permit is issued,t shall employ persons subject to workman s compensa- tion laws of California." 4 The applicant must call for all required inspections. Complete drawing on reverse side. Date: Title: T s fes. �..Oray � Signed X € FOR ONLY Date~ ( Application Accepted by Dat ►. Pit or Grout Inspection by Date— Final Inspection b Additional Comments: 466-6781 CJ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 ❑ Stk : alth Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 Applicant Return all copies toEnvironmental He yPERMIT No. �. FEE AMOUNT iDUl= AMOUNT REMITTED CASH RECEIVED BY DATE INFO ! 7 5;��—[n —9-7O EN 13-24 MEV.1/R sl ' EH 14-28