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•�aA APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT " 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) construct and/or install the work herein described.This application is Application is hereby made to the San Joaquin Local Health District for a permit to made in compliance with San Joaquin Conty Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local health District. �u� V/7[ S�{ � �: City o tat Size PM Jo Address o/ /[/ Phbn Address Owner's Name W License .No377�1�-5 Phone Address Contractor s� T _ WELL REPLACEMENT ❑ DESTRUCTION ❑ YPE OF WELL/PUMP: NEW WELL PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEF1'IC;..TAN K` lis] _ SEWER LINES' Z.Ta--.— DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL { PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation T e of Casing 'M� Specifications �omesticIPTivate Gravel Pack ❑ Tracy yP g I ❑ Delta Depth of Grout Seal '�t Type of Grout 11 Public [1 Other • S i Depth 3 t I Eastern Surface Seal Installed by 1 irrigation —.Apprax V t I Slate Work Done Repair Work Done ❑ Type of Pump �� H.P. I Well Destruction ❑ Well Diameter Sealing Material hop 501 IT- Depth ' Filler Material {Below 50'1 RK: NEW INSTALLATION l 1 REPAIR/ADDITION L i .DESTRUCTION i I Jo aNpti csystem permitted if public sewer is TYPE OF SEPTIC WOailab Installation will serve: Residence Commercial— Other IT " Number of living units: Number of bedrooms: ' � r � Water table depth Character of soil to a depth of 3 feet: SEPTIC TANK ❑ Type/Mfg Capacity No, Compartments PKG. TREATMENT PLT. ❑ Method of Disposal .t µ s' Distance to nearest: Well Foundation Property Line i LEACHING LINE CI No. & Length of lines Total lengthtsize EFILTER BED El Distance to nearest: Well Foundation Property Line } SEEPAGE PITS l I Depth Size Number SUMPS . ❑ Distance nearest: Well Foundation Property Line DISPOSAL PONDS' ❑ f, ' 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 rules and regulations of the San Joaquin Local Health District. 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 shall not employ any person in such manner as to become subject to workman's compensation taws of California."Contractor's hiring or sub contracting signature certifies the following: "4 certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applicant must all for II req d inspectioris. Complete drawing on reverse side. k'11�_ R Signed Title: r�4t 1 l Date: X , FOR DEPARTMENT USE ONLY' Date � Application Accepted by Area Pit or Grout Inspection by ` t Date Final Inspection by Date� - ' r f Additional Comments: gr ❑ Stk 466-6781 ❑ LoFK 369-3621 ❑ Manteca 823-7104 ❑ Tr cy 835-6385 Applicant- Return all copies to:.Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED r CK RECEIVED BY DATE {� PERMIT'NO, + EH13-24iREV.iinSi ---.,�j i } r 6� l I� , EH 14.26 1�J