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APPLICATION FOR PERMIT SAN JOAQUINLOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephlone 12091 .466-6781 PERMIT EXPI11i YEAR FROM DATE ISSUED { '(ComIplete in Triplicate) kr+.. a application is Application is he+eby made to the San Joaquin Local Health Districtfora permit to construct and/or install the work herein described.This app made in compliance-withis a e t Joaquin County Ordinaync No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. 4 r!��"l City Lot Size /// PM Job Address ' €Mr Phone' Owner's Name f d ni—� • • ` �" �q License No: �-joj Phone Contractor�2m _ —ad TYPE OF WELL/PUMP: NEW WELL El ELL REPLACEMENT El DESTRUCTION EJ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑- OTHER ❑ r DISPOSAL FLD. PROP- LINE DISTANCE TO NEAREST: SEPTIC TANK SEWER;,LINES FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS pia. of Well Casing ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Specifications l l.. EJDomestic/Private - ❑ Gravel Pack [ITracy Type of Casing [1 Public F1 Other 171 Delta ! Depth-of-Grout Seal -Type of Grout I I Irrigation -Approx. Depth I 1 Eastern Y Surface Seal Installed by Repair Work Done El Type of Pump H P f€ State Work Done _ Well Destruction ❑ Well Diameter Sealing Material (top 50' - # Filler!MateriallBelo '! Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDI I ION DESTRUCTION i I aNailabPe1wit tri 20c system 0 feet.) if public sewer,is ._, - �p - - . Installation will serve: Residence h Commercial other Number of living units: Number of bedrooms Water table depth depth of 3 feet: Character of soil to a p ❑ Type/Mfg Capacity No.,Compartments SEPTIC TANK h Y Method of DVal PKG. TREATMENT PLT. ❑ {'V j Property Line Distance to nearest: Well O t Foundation k LEACHING LINE ❑ No. & Length of lines M Tota! length/size FILTER BED ❑ Distance to nearest: Well k Foundation Property Line C� Number 4 M SEEPAGE PITS f I Depth W f ,� Property Line PISPOPSAL L1 Distance to nearest: Well(1✓�(L— Foundation 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.!1 -, t' i 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 employ any person in such manner as to became subject to workman's compensation laws of California." Contractor's hiring or sub contracting signatur certifies the following:,"I certify that in the performance of the w rk for which this permit is issued,I shall employ persons subject to workman's compensa- tion laws of California." The applicant u II for all u ed inspections. omplete drawing on se side. ` �( .,�j Date:` 10if Title: 1 -y ,. Signed X R DEP RTMENT USE ONLY 7-1 � Date Area Application Accepted by G Date t� Final Inspection by Date I Pit or Grout Inspection by . Additional Comments: i 0 Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 1823-7104 ❑ Tracy 835-6385 i Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 CK 1 _ i CASH RECEIVED BY DATE PERMIT NO. FEE AMOUNT DUE AMOUNT REMITTED INFO (J� l (y e �V' . EH 13-244111iH5) OU n EH 14-29 r -