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APPLICATION FOR PERMIT SAN JOAO:UIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA �. Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM MATE ISSUED'` (Complete in.Triplicate) ;�,r:F��„rrx!,l:#oc.t '.14 �� application is Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the workRules aerainvde Regulations of s app made a oncomplianceisb with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Roles and Regulations of the San Joaquin Local Health District. + 3 �` APM Lot Size O 1 City Job Address ' .. '' ddress Phone / oLOU r Owner's Name Address I '0- 'License No 3 Phone r Contractor DESTRUCTIO TYPE OF WELLIPUMP: NEW WELL "ti WALL REPLACEMENT ❑ SYSTEM REPAIR. ❑ OTHE ❑ i PUMP INSTALLATION &e oo r DISPOSAL FLD. PROP. LINE `S TO NEAREST: SEPTIC TAN SEWER LIGE$ �., PITS/SUMPS I " DISTANCE { AGRICULTURE WELL OTHER WELL FOUNDATION i INTENDED USE TYPE OF WELL PROBLEM AREA I CONSTRUCTION SPECIFICATIONS / pia_ of Well Exca to Dia. of Well Casing ❑ Open Bottom ❑ Manteca ❑ Industrial Ell Type of Casing ! Specifications j ❑ Domestic/Private C�Gravel Pack / Type of Grout If ❑ Other ❑ Delta .Depth of Grout Seal a 4� RrIublic ❑ Irrigation _�pprox..Dep ❑ Eastern , urface Seal Installed by H P State Work one Repair Work-Done 0 Type of Pump D Sealing M , aterialjtop 50'1 U} Well Destruction ❑ Well Diameter Filler Material [Below 501 Jt Depth EOF SEPTIC WORK: NEW INSTALLATION Ll REPAIRIADD ION ❑ DESTRUCTION L3availableiwtsystem n200 feetitled if public sewer is Commercial�r Other .....►. `7 installation wi e: Residence 4u(ry� 7 ' nits:— Number of bec�ravms" - Number of living u \ b ., , ,r �� }� Water table depth -� Character of soil to a depth of 3 fe Capacity_ No. Compartments SEPTIC TANK ❑ Type/Mfg j y� Method of Disposal PKG. TREATMENT PLT. Ll -4 s •" '�on„��- Property Line W Distance to nearest: We11 f' Dandeli l , .,� y '.,.t`'. ',=° - al length/size E 4 - 'LEACHING L1NE ❑ No. & Length of lines Foundation on j rty Line FILTER BED ❑ Distance to nearest: Well E t 4 �- Number SEEPAGE PITS ❑ Depth -Size Property Line ❑ Distance to nearest: Well i Foundation i 1 SUMPS I I DISPOSAL PONDS El ' lication and that,the work.will,be done in accordance with San Joaquin county ordinances, state laws, an 1 hereby certify that i have prepared this app' Gr—which rules and regulations of the San Joaquin,Local Health.Dist�ict.gwork 4 this permit is issued, I shall not Home owner or licensed agent's gas to subject jto workman's compensation lawsofCalifornia.”Contractor's thir ng or sub-contracting signature employ any person in such sa- certifies the following:"I certify that in the performance of the work for which this permit is issue I shall employ persons subject to workman's compen tion laws of California." -` The applican ust Il for alt re ed inspections. omplletedrawing on re erseside' pate: Title: Signed X_ r FOR DEPARTMENT USE ONLY G/_ Area 111Z V Date ? Application Accepted by ece'11''9111 Date I • Date 3 43(— Final Inspection by Pit or Gro Inspection by pit Ap l32 l Coe �a hc, . A i' ❑ Manteca 823 71 ❑ Tracy 835-6365 4-rowtt SQ ❑ Stk 466-6781 ❑ Lodi 369 3621 P.O. Box 2009, stk., CA 95201j Applicant- Return all copi s to: Environme al ealth Permi ervices 1601 E. Hazelton Ave., ✓ 2-1 1 PERMIT'NO.f CK* RECEIVED ByDATE FEE AMOUNT DUE AMOUNT REMITTED CASH INFO W A-I +EH 13-24(REV.1/B5) EH 1426 -