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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL—1 ON AVE., STOCKTON, CA j Telephone (209) 466-6781 J i175� /r�� ipERMIT EXPIRES 1 YEAR FROM DATE ISSUED i (Complete in Triplicate) permith District for a construct andlor install the work herein cat on is Application is hereby made to the u nnCo aquiunty Localncfe Nto.549 for sewage or No. 1862 forwelllpump and the Rules and Regulations of tris l he SanJoaquin made in compliancea with San q Local Health District. I Job Address V4)K /v City—4o i Lot Size PM �r Address GUAQ PhoJi�3`701 Owner's Name [ Contractor G ,�• Address �d �dX !7a License No3 2734T Phone Z'r t DES _ TRUCTION'❑ TYPE OF WELL/PUMP: r: "/' NEW WELL WELL REPLACEMENT - -� •" ❑L - P.UMP.INSTALLATIONg ----�- �-- SYSTEM REPAIR-❑ - T^�^ OTHER_ aO.. SEINER LINES, DISPOSAL FLD. PROP. LINE DISTANCE TO NEAREST: SEPTiC TANK. it _ -�_r. OTHER WELL — PITSISUMPS FOUNDATION r+ AGRICULTURE'WELL INTEND♦ USE TYPE OF WELL PROBLEMAREACONSTRUCTION SPECIFICATIONS Dia. of Well Casing Industrial ❑ Open Bottom ' ❑ Manteca Dia.of Well Excavation i Specifications Gravel Pack ❑ Tracy Type of Casing r i T Domestic/Private I t! Type of-Grbut• C tA� (A De Depth of Grout Sea �- M Public 171 Other 3 Approx. Depth I 1 Edstorn Surface Seal Installeii,by t' 1 1 Irrigation - H P - I State Work Dane i Repair Work Done C7 Type of Pump _<5 -- .-r--�-- Sealing Material Itop 50'1 I Well Destruction C7 Well Diameter,, Depth Filler Material (Below 501 rTYPE OF SEPTIC WORK: NEW INSTALLATION ['I REPAIR/ADDITION ( I DESTRUCTION !'L aGailablelw thin 200 f tined if public sewer is 1 Installation will serve: Residence Commercial Other s t Number of living units: Number of bedrooms �✓` Water- Character depth c Character of soil to a depth of 3 feet,," af No Gompartments SEPTIC TANK L1Type/Mfg Capacity Method of Disposal -- PKG. TREATMENT PLT. ❑ ( +, Property Line Foundation Distance nearest: # well, g ;_j �y Total Length/size LEACHING LINE ❑ No. & Length of lines Pro ert Line FILTER SED ' r ❑ Distance to nearest: Well Foundation"' P y Number SEEPAGE PITS I I Depth Size 1' SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS .+ ❑ I hereby certify thMt I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of ythe'San Joaquin Local Health District. ` Home owner or license agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not k employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring ort to -cokmaniscompensa- nature certifies the following: "I certify that iri the performance of the work for which this permit is issued, I shall employ pe I tion laws of California." inspections. Complete drawing on reverse side. The applicant must call for all required / Title: 13A Date. Signed X lT �`'�� FOR DEPARTMENT USE ONLY Date Area Application Accepted b Date P Final Inspection by Da e Pit or Grout Inspe io y 1 Additions{ Comments: 4/1 f/I 41; ❑ 5tk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 Tracy B35-6385 th Permit/Services 1601 E. Hazelton Ave., P.O. Box 2{)09, Stk., CA 95201 Applicant - Return all copies to: Environmental Heal CK RECEIVED BY DATE PERMIT NO. FEE AMOUNT DUE AMOUNT REMITTED CASH p ri�qa / :��.,,y'y'� g (?Z +.EM 73.24(REV.1/n sf EH.-14-25