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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEACTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA. Telephone (209) 466-6781 ' PERMIT EXPIRES 1"YEAR FROM DATE ISSUED -- •-� �"^ " (Complete in Triplicate) -* lication is aA, Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This app Applica compliance with San Joaquin Gounry Ordinance No.549 for sewage or No. 18 for well/pump and the Rules and Regulations of the San Joaquin made Local Health District. •} -7yi City /r `Lot Sipe PM Job Address r�31r -2 9 a�7 �Qwner's Name Address J� if Phone �ss I -71 _' , IPhone_ Contractor A Address es License No. *, F "TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT LJDESTRUCTION S❑t +. t PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ ' DISPOSAL FLD. 11 ". PROP. LINE DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES i 5 1 FOUNflATION AGRICULTURE WELL OTHER WELL �M PITS/SUMPS i INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS pia. of Well Casing t .❑ Industrial"f ❑ Open Bottom ❑ Manteca Dia. of Well Excavation } Type of Casing (M Specifications jr -❑ Domestic/Private ❑ Gravel Pack ❑ Tracy yp IM Type of Grout `! - FI Public Other i Cl Delta Depth of Grout Seal t rr i1 1 Irrigation Approx. Depth . ij I Eastern Surface Seal Installed by l - * = H P. State Work Done Repair Work Done ❑ Type of Pump Well Destruction ❑ Well Diameter Sealing Material (top 50'IT _ t it Depth Filler"Material I8elow 50'1 1TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIR/ADDITIO DESTRUCTION I 1 (No septic,�system permitted if public sewer is f tvi 1 available within 200 feet.' , —,W I installation will serve: Residence— Commercial ther Number of living units: Number of bed Water table depthY Character of soil to a depth-of 3 feet: § i Capacity No. Compartments ,SEPTIC TANK ❑ i Type/Mfg r Method of Disposal PKG. TREATMENT PLT.❑ Pro ent Lil Distance to nearest: Well Foundation P Y ne 3 f Total length/size LEACHING LINE ❑ No. & Length of lines / a „r 1 r ® Foundation Property Dine 3 FILTER BED ��" ❑, Distance to nearest: Well�— I SEEPAGE PITS I i Depth Size Number G 4J' Ll Distance to nearest: Well Foundation Property Line SUMPS 11 'DISPOSAL PONDS ❑ 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. t 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, !shall not employ any person in such manner as to become subject to workman's compensation laws-of California'-Gontractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, i shall employ persons subject to workman's compensa- 1N, tion laws of California." The applicant'mus jail all required inspections. Complete drawing on reverse side. Signed X Title: y Ct! `� LDate: (� F EIPARTMENT USE ONLY Date !il Area t, Application Accepted by I: s 'Pit or Grout Inspection by Date Final Inspection by 'Additional Comments: ❑ Stk 468 8781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 EDTracy 835-6385 Applicant- Return all copies.to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2409, Stk., CA 95241 .� FEE AMOUNT REMITTED CK RECEIVED BY �� DATE PERMIT'NO. I AMOUNT DUE CASH INFO - r /x� (J f� +..EH13-24'inevriTK5i .. °� ,V/l`•. �' �,.,,t- 10 EH 11-28 1� V. I' j