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o APPLICATION FOR PERMIT ' SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZETON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) cation is Applicationi ieb with a to the San Joa P Joaquin Courcy Ordinance lNto. 549 for sewage orh District for a 'No. 1862 for t to cwell/dpump install nd the Rules and IR Regulations of This he San l Joaquin made incompliance Local Health District, SEEPAGE PITS I l Depth I Size SUMPS ❑ Distance to nearest: Well 1 Number Foundation Property Line I DISPOSAL PONDS ❑ 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, stale 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 signature employ any person in such manner as to become subject 10 workman's compensation laws of California." Contracgonslsub cring rsub-contracting t to workman's compensa- certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ p I tion laws of Calif The applica must fo 11 squired inspections. Complete drawing:]Z�r Signed X Title:d(-Date: FOR ARTMETIT USE ONLY /� J Date Area Application Accepted by "t - Date � Pit or Grout Inspection by " Date Fina! Inspection by .�-.liae. k rf r Additional Comments: 171 Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑Tracy 835 6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY ii DATE PERMIT' NO. �{ INFO ♦ EH 13-24 (REV. i / x 5) ®p � EH 14-26 City d Lot Size PM �� Q M1 D Job Address __!R: Owner's Name. i Address 23 D� " a f - Pnone(11Ph �y QO License No. o e b l I Contractor l f Address NEW WELL f7WELL REPLACEMENT ❑DESTRUTION • _' TYPE OF WELL/PUMP:. REPAIR ❑ OTHER ❑ PUMP INSTALLATION :1SYSTEM DISPOSAL FLD. PROP. LINE DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES OTHER WELL PITS/SUMPS FOUNDATION AGRICULTURE WELL INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia of Well Casing ❑ Industrial ❑ Open Bottom ❑ Manteca Dia- of Well Excavation Specifications ❑ Domestic I Private ❑ Gravel Pack ❑ Tracy Type of Casing t❑ Depth of Grout Seal Type of Grout f`I Public Delta Ll Other _ Depth i I Fastern Surface Seal Installed by I I Irrigation _Apprax --Approx. H.P. State Work Dane Repair Work Done C7 Type of Pump ��%%U Sealing Material (top 501 Weil Destruction Well Diameter _�1f. Depth r� Filler Material (Below is TYPE OF SEPTIC WORK: within 200 feetiued if public sewer NEW INST' LLATION I.I REPAIRlADDITION i I DESTRUCTION i I availableseptic Installation will serve: Residence 4 Commercial _ Other Number of of living units: _ Number of bedrooms Water table depth Character of soil to a depth of 3 feet: No. Compartments Capacity I SEPTIC TANK ❑ Type/Mfg Method of Disposal PKG. TREATMENT PLT. ❑ 4 pro ert Line Foundation P Y Distance to nearest: Well Total length /size ❑ No. & Length of lines LEACHING LINE FILTER BED Property Line ❑ Distance to nearest -.Well Foundation pery A SEEPAGE PITS I l Depth I Size SUMPS ❑ Distance to nearest: Well 1 Number Foundation Property Line I DISPOSAL PONDS ❑ 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, stale 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 signature employ any person in such manner as to become subject 10 workman's compensation laws of California." Contracgonslsub cring rsub-contracting t to workman's compensa- certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ p I tion laws of Calif The applica must fo 11 squired inspections. Complete drawing:]Z�r Signed X Title:d(-Date: FOR ARTMETIT USE ONLY /� J Date Area Application Accepted by "t - Date � Pit or Grout Inspection by " Date Fina! Inspection by .�-.liae. k rf r Additional Comments: 171 Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑Tracy 835 6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY ii DATE PERMIT' NO. �{ INFO ♦ EH 13-24 (REV. i / x 5) ®p � EH 14-26