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APPLICATION FOR PERMIT 1 SAN JOAQUIN LOCAL HEALTH DISTRICT p 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 k PERMIT EXPIRES 1'YEAR FROM DATE= ISSUED 1 (Complete in Triplicate) I `�`�3PN A ESL H ; Ai6lktiie' b1K ,i he San Joaquin Local Health District for a permit to construct and/or install the work herein described.This application is made c with San Joaquin Co6 my Ordinance No:549 for sewage or No. 1862 for wekllpump and the Rules and Regulations of the San Joaquin k Local Health District. City t Lat Size PM Job Address I8G0 W� Phone !)451 Owner's Address Owner's Name �/ �r ]_, l' -14127 4,;V,e a f� License No. Phone 33$1-f/30 Address Contractor DESTRUCTION ❑ - WELL ❑, M WELL REPLACEMENT a TYPE OF WELL/PUMP: NEW r .., OTHER ❑ _ _PUMP INSTALLATIO ❑ - ' SYSTEM REPAIR ❑ SEWER LINES DISPOSAL DISTANCE TO NEAREST: SEPTIC TANK FLD._. _. PROP. LINE 'ice✓+ k FOUNDATION AGRICULTURE WELL OTHER WELL �� PkTSISUMPS _ INTENDED USE TYPE OF WELLN- PROBLEM AREA CONSTRUCTION SPECIFICATIONS �{ Dia. of Well Casing ❑ Industrial i '` Open.Botfom t❑.Manfeca'& 0!a• of Well-Excavation y� , Type of Casings r' Specifications ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy _ - E_,•e,Type of-Grout - " ( } Other r Depth of Grout-Seal ❑ P66116 ❑ Delta �.Approx�Depth I 1 Eastern Surface Seal installed by ; rrigation r H P State Work Dane_ ! Repair Work Done ❑ Type of Pump • Well Destruction ❑ Well Diameter Sealing Material Stop 501 Depth Filler Material IBelow 50`1 ` T ..? �. yste TYPE OF SEPTIC WORK: NEW INSTALLATION I'i REPAIR/ADDITION l i DESTRUCTION I I (No sb tt'avaw Thin 200 feet.)edif public seweryis i { l Installation will serve: Residence_ Commercial Other 4 Number of living units:. Number of bedrooms Fk Water table depth Character of soil to a depth of 3 feet: - No, Compartments !: Capacity < � SEPTIC TANK © Type/Mfg Id Method of Disposal 1 PKG. TREATMENT PLT. ❑ .i - � Distance to nearest: Well ation Property Line ,. ' 1 14 Total length/size LEACHING LINE ❑ Nri.t&}Length of.lines I , Property Line .l FILTER BED '�❑_; Distance to nearest: Well Foundation ' - : w Number SEEPAGE PITS, _I I Dep °-- Size , 3 indationi Property Line L] Well Fou SUMPS Distance to nearest" F DISPOSAL PONDS ❑ "' application and that the work will be(done in accorda'rice with San Joaquin county ordinances, state la W'' I hereby certify that I have prepared this app r rules and regulations of the San.Joaquin Local Health District. "P t , Home owner or licensed agent's signatare certifiestttie following: "1 certify,it6vin the perfb gmance of the work for which this permit is issued, I shall not employ any person in sibinature such manner as to hecome.subject to workrftn's co`rnpensation laws Cgf California."Contra ebsonsl5ubjecring rt to workrn nt!sgcompensa- re certifies the following:"I certify that in the performance of the work for which this permitis issued,i shalk employ p tion laws of California." f f The applicant st EgLig.Lall requir inspe Complete draw ing-on reverse side. m ' * Date: i it e: e Signed X FQ8 DEPARTMENT USE ONLY. t ;pate Area \� Application Accepted by f ° ► Cd-' Data '•- FinalIDate nsection by r Pit or Grout Inspection by ., 'j p Additional Comments:nts: -- • El Stk 466-6781 ❑ Lodi 369-3521 ❑ Manteca 823-7104 I] Tracy 835 6385 1 Applicant Return vnm I HealthPermit/Services 1601 E.�Haz�e}Itonve., P.O. Box 2009, Stk., CA 95201 — F l �.- OUNT DUE Aril10UNT REMITTED CK RECEIVED'13YY '^ DATE PERMIT'NO. ~ q ,CASH ,� 1114 � 1! +EH 13-241REV.1/115t EH 14-26 _