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i APPLICATION FOR PERMIT 'S _ v SAN JOAQUIN LOCAL HEALTH DISTRICT �S 1601 E. HAZELTON AVE., STOCKTON, CA Telephone {209} 466-6781 -< PERMIT EXPIRES 1 YEAR FROM DATE.ISSUED tLIA, d work (Complete�in Triplicate} t and/or install the I cation is Application is hence with San Joaquin County O dinaoaquin the San Jlnce No.District Health 549 for sewage or permit No. 1862 for cwell/Pump apd>he Rules and Regulationsofof the San r Joaquin made in comp N� -� Local Health District.. City Lot Size PM I Job Address ki wC�/ l/ �� :J • T�JV/C/e Phone J� ` Owner's Name Address Address License No. Phone Contractor TYPE OF WELL/PUMP: i� NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP I TALLATION 1-2SYSTEM REPAIR 17 OTHER ❑ DISTANCE TO NEAREST: SEPTIC TA SEWER LINES AG E WELL OTHER WELL PITS/SUMPS FOUNDATION INTENDED USE TYPE OF WE ROBLEM AR NSTRUCTION SPECIFICATIONS tion Dia. of Well Casing ❑ Industrial ❑'! ottom ❑ Manteca Dia. of a Specifications ❑ DomesticlPrivat ❑;Gravel Pack ❑ Tracy Type of Casing ❑ Delta Depth of Grout Seal Type of Grout ID Public ' � Other ❑ IrrigationJI_Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Tye of Pump H.P. p + -... State Work Dane Sealing Material (top 50'1 Well Destruction - Ll Well Diameter g t Qli p Filler Material (Below 50') E TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTIO { ailabpe�within 200 feet.)ermitted"rf public sewer is installation will serve: Residence Commercial— Other Number of living units: Number of bedrooms —"" Water table depth Character of soil to a depth 0 feef:" No. Compartments Capacity f SEPTIC TANK ❑, Type/Mfg r Method of Disposal PKG. TREATMENT PLT. ❑ Property Line f ; I Distance to nearest: Well Foundation s 1 I F 3 Total length/size + LEACHING LINE ❑p. No. & Length of lines � Property Line FILTER BED O Distance to nearest: Well Foundation I I� ; Number _l SEEPAGE PITS d Depth Size -- y i SUMPS ❑l Distance to nearest: Well Foundation Property Line r DISPOSAL PONDS Cl __ I hereby certify that I have 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. performance of the work for which this permit is issued, l shall no Home owner or licensed agent's signature certifies the following: "I certify that in the signatu t employ any person in such!manner as to become subject to workman's compensation laws of California." Contractor's hiring to workman's certifies the following:"I c rtify that in the performance of the work for which this permit is issued,I shall employ p s t tion laws of California." y The applicant must call fo.all required in ctions. Complete drawing on reverse side. y �� IN Title: Date: Signed t II� FOR DEPARTMENT USE ONLY Date Application Accepted by II� I Date Final Inspection by Date Pit or Grout Inspection /— Additional�Comments: a ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant= Return all ccesto: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 li li FEEHE. AMOUNT REMnTED RECEIVED 9Y DATE PERMIT"N0. INFO EH 13-24 IREV.t/e 51EH 14-28 I"