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r •-- APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEARTH DISTRICT 1601 E. HAZEL T ON AVE.,t STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED {Complete tri Triplicate) ' Application is hereby made to the San Joaquin Local Health District for a permit to constr e ' 1 made in compliance with San Joaquin County Ordinance lth 1+ .k the work herein described, THs ap Local Health District, ,r ry 549 for sewage or.No. 1862 for cwellpump and l the Ryles and Regulation. cation is of Pll' the 5Joa s rsrF �J _ r _tf Joaquin q Owners Name 4 4. r+ ity Lot Size•_, s� PM a ; r L5 Address 5- F .. Contractr 1 r �� ` Phone J Address TYPE OF`WELL'/PUMP; 'License NSW WELL ❑ No. PUMP INSTALLATION ❑ WELL REPLACEMENT ❑ ��—Phone DISTANCE TO NEARLZL-iEST: SEPTIC TANK SYSTEM REPAIR ❑ DESTRUCTION El —� SEWER LINES OTHER ❑ ---�- FOUNDATION AGRICULTURE W-~ DISPOSAL FLD,� PROP LINE INTENDED USE TYPE OF WELL —� OTHER WELL�L PITS/SUMPS �( , ❑ lndustriaf PROBLEM AREA CONSTRUCTION SPECIFICATIONS J rV1 ❑ Open Bottom ❑ Man w ❑ Domestic/Private ❑ Gravel Pack Dia. of Well Excavation D Public ❑ Other ❑ Tracy Type of Casing Dia. of Well Casing Q Irrigation L3 Delta Depth of,Grout Seal Specifications Repair Work Done ---Approx. Depth El Eastern Surface Seal Installed by - Tye of Grout ❑ Type of Pump H.P. -Well Destruction EJ Well Diameter " �"— --- State Work Done y Depth ~ Sealing Material (top 50') \ p TYPE OF SEPTIC WORK: NEW INSTALLATION Miler Material (Below 50') \`\1 `t REPAIR/ADDITION ❑ 'DESTRUCTION ❑ (fVo septic system permitted if public sewer is 1 Installation will serve: Residence Z1, Commercial Other`1 available within 200 feet.) Number of living units: Number f bedrao s Character of soil to a depth of 3 feet: ✓ SEPTIC TANK // - Type/Mf i 4 �" s Water table depig `7 PKG. TREATMENT PLT. [3 ' "^"`�^- - � Capacity No. Compartments Distance to nearest: Well t Method of_Dfsrpflsal •-. y Foundation _ _ LEACHING LINE Property line F p l�7 No. & Length of lines- FILTER BED ❑ Distance to.nearest: Total length size x `' ' fWelf Foundation_ Property Line SEEPAGE ITS 51 Depth 1 SUMPS Size ❑ Distance to nearest: " Well ` `Number DISPOSAL PONDS ❑ o - Fouridation --.� Property Line I hereby certify that I have prepared this application and that the work wilirbe one in accordance wt Sa rules and regulations of the San Joaquin Local Health District. � ;atm n�J aq vn county ordinances, state laws, and Home owner or licensed agent's signature certifies the followfn `fy 1 employ any person in such manner as to become subject to workman s compensation laws of California,'r Coritractor's hiring or sub o tracting signature the performance of the,work for which this permit isoissued, I shall not certifies the following:." certify that in the performance of the worklf I r which this permit is issued, i shall empfoypitor'srsonsubject to workman's compensa- tion Paws of California." The applicant 1 ust call for alleq 'red inspections. Complet Complete drawing on reverse side. ry Signed Title: Date: C Gci ,FOR DEPARTMENT USE ONLY Application Accepted by r l�' bate r 'Are Pito Grout Inspection by IIIIIv Additional Comments: �._ t T Date F�nspectibn by ❑ Stk 466-6761i ❑ Lodi 36g-362 Applicant- Return all copies to: Enviro1 El Manteca 823-7104 El Tracy 835-6M nmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 . - - aaA�, FEE ,; a _v INFO ,'AMOUNT DUE,. AMOUNT REMITTED CK# CASH RECEIVED BYEEH 13-241REv.sis51 J � PERMITNOEH 14-26 "�SS. .�55 164 1