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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT ` 1601 E. HAZEL T ON AVE�.� STOCKTON, CA Telephone (209) 466-6781 a PEFIMIT EXPIRES 1'YEAR FROM DATE ISSUED (Complete in Triplicate) application is sewage or No. JB62 for well/pump and the Rules and Regulations of the San Joaquin made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This Application is hereby Ordinance No.-549 for g 'made in compliance.with San Joaquin County Local Health District. -� �l _ . pM�— City Lot Size Job Address �7 Phone Address !'1 I Owner's Name9� License No �S Phone_ E Address — DESTRUCTION ❑ Contractor L L5WELL REPLACEMENT NEW WELOTHER ❑ TYPE OF WELLIPUMP: SYSTEM REPAIR ❑ P. LINE PUMP INSTALLATION ❑ DISPOSAL FLD. PRO SEWER LINES �---- �} PITSISUMPS .� DISTANCE TO NEAREST: SEPTIC TANK _---- AGRICULTURE WELL OTHER WELL-�— X t FOUNDATION T TYPE OF.WELL PROBL_ EM AREA CONSTRUCTION SPECIFICATIONS Dia of Well Casing ❑ Manteca Dia. of Well Excavation INTENDED USE ❑ Industrial L) open Bottom ,Specifications t ❑ Domesticl Private , ❑ Gravel Pack © Tracy Type of Casing Type of Grout f / Cl Other ` F1 Delta Depth of Grout Seal _ ['1 Public Surface Seal Installed by + I I Irrigation —.-Approx. Depth t I Eastern State Work Done Type of Pump —�� H.P. Repair Work Done ❑ Sealing Material (top 501 Well Destruction ❑ Well Diameter --- Filker Material (Below 5d'1 ,41 { Depth SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION DESTRUCTION I l iNo septic system permitted it public sewer as available within 200 feet.) TYPE OF SE. a; 'E e _/ F Y Commercial Other Installation will serve: Residence, lJ7f Number ofI living units: L Number of b ro ms - - Water table depth 7 Character of soil to a depth of 3 feet: �j Capacity — No. Compartments SEPTIC TANK ❑ Type/Mfg �f l t; Method of Disposal PKG. TREATMENT PLT. ❑ 1 •Propegy,Line ' 'Foundation � f ' i Distance to nearest: Well �. V f --Total length/size � o-N & Length of lines __ � .. f �- `y0 j I Foundation P�party Line LEACHING LINE r FILTER BED ❑ Distance to nearest: Wellf h ■ F F f : I �/DepthSize SEEPAGE PITS t ' "Nell_,&Q_6_11_1_Foundation ion i Nur mherPro = Cine Distance to neares SUMPS ❑ � �i t DISPOSAL,PONDS - I hereby certify that I have prepared this application and that the work will be done in ac ai�e,w\.San Joaquin aunty ordinances, state laws, and rules and regulations of the San Joaquin Local Health4 District. 1 Home owner or licensed agent's signature certifies the following:"l certify that in the performance of'the work for which this permit is:issued, 1 shall not employ, y�P in the rformance of the work for wfiich this permit is.issued,l shall employ persons subject to workman's compensa an arson in such manner as to become_subject to workman's compensati in-laws of California.';Con'tractor's hiring or sub-cont racting signature r certifies the.following:"I certify that Pe ` s' r tion laws of California." I € i The applica mus all for all req ed in ctions._. Com_p�ge drawing on reverse side. ��r � — Date E d X Title: V' ! 'Signe � � a S ,r FOR DEPARTMENT USE ONLY Date Area ` Application Accepted by I Date Final Inspection byT. Pit or Grout Inspection by L Additional Comments: t _ 635=6385,.___ ,. Q Stk 466-6781 ; ❑ Lodi:,369-3621..y,,,. 11.Manteca,,.823 7104 D Tracy Applicant Return all copies to:'Environmental Health Permit/Services 601�E. Hazelton Ave., P.O. Bax 2009, Stk., CA 95201 CIS RECEIVED BY DATE PERMIT NO. FEE AMOUNT DUE AMOUNT REMITTED CASH INFO 17 +.EH 13-24 IREV. i 8!5) J 2 �� EH 14-2e k -