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J _ APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT ' TON AVE. STOCKTON, CA 1601 E. HAZEL Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED JUL � $� I (Complete in Triplicate) ENVIRUjrIFENTAL HEALTH FFftfihil4��1 /kation is Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the wor pp made in compliance with San Joaquin County Ordinance No.549 for sewage.or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. l City Lot SizePM Job Address � rl Q Owner's Name Address one Contractor's Name _ f.0 L License No. ��Q �� — Phone TYPE OF WELL/PUMP: NEW WELL,1k4, WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST:_SEPTIC TANK�IOZ- SEWER LINES DISPOSAL F� _ PROP.:!_IIUE .L R .• . FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATION ❑ Industrial ❑ Open Bottom E3Manteca Dia. of Well Excavation Dia. i f Well Casing (Q Domestic/Private XGravel Pack# ❑ Tracy Type of Casing Specifications r,. C1 Public ❑ Other I11 ❑ Delta Depth of Grout Seal / Type of ut \W ❑ Irrigation Approx.,Depth ❑ Eastern Surface Seal Installed by— Repair y Repair Work Done ❑ Type of Pump l_ H.P. State Work Done Well Destruction ❑ Well Diameter , (Sealing Material (top 501. Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No sept7de system in permitted if 3,s Installation will serve: Residence._ Commercial— Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: I W ee, I SEPTIC TANK ❑ Type/Mfg Capacity NsPKG. TREATMENT PLT. ❑ MalDistance tonearest: Well Foundation PropertyLEACHING LINE ❑ No. & Length of lines Total length/siz FILTER BED ❑ Distance to nearest: a Well Foundation Property Line , SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation_ Property Line •JIJ''i"~'v'.r.,!'9 i�Y'V IVIJ��!U- ..�� •aTl��'��,+�YliM�y sr 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. k 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 I! employ any person in such manner as to become subject to workmen's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following: "l certify that in the performance of the work for which this permit is issued,I shall employ persons subject to workman's compense- tion laws of C lifornia." The appli must tali for all requi inspections. ompleta drawing o verse si ' 4 Title: Date: 7 Signed FOR,DEPA MENT USE ONLY � ^�rea Application,Accepted by vv Date — r!✓�a Pit or Grout Inspection by Date Final Inspection by Date (nsnG+ny-- ? . L1 " Additional Comments: - f,/ � 0 E l' J��' Y°°} y I ,V-�c4 P-Cvro vi -C ver r r t rj I C7 Stk 466-6781 ©Lodi 369-3621 CJ Manteca 823-7104 ❑ Tracy 635-6365 , Applicant- Return all copies to: Environmental Health Permit/Services 1601 F. Hazelton Ave., P.O. Box 2003, Stk., CA 95201 FEE AMOUNT DUE r AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. INFO f/ -7— t 7 t EN 13-24 MEV.19183) 143 00 7 q(p'7 y W /T EH 74.26