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APPLICATION FOR PERMIT DISTRICT SAN JOAQUIN LOCAL HEALTH . -y 1601 E, HAZELTON AVE., STOCKTON, CA C'1 1987 Telephone {209) 466-6781 E r PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ENVIROMENTAL HEALTH A (Complete in Triplicate) FERMIT/SERVICES Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin r Local Health District. City Lot Size PM Job Address Owner's Name �D Q Address Phone rE2 Address icense No. Ptho Contractor EMENT ❑ DESTRUCTION ❑ ❑ TYPE OF WELL/PUMP: . ,. ..... NEW WELL - WELL REPLAC PUMP INSTALLATION V C&pAM,�M ;Y STEM REPAIR ❑ OTHER ❑ SEWER LINES DISPOSAL FLD. PROP. LINE DISTANCE TO NEAREST: SEPTIC TANK _ �. _ - - -_— 'PITS/- - FOUNDATION s AGRICULTURE WELLOTHEfl WELLLLSUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS pia. of Well Casing ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Type of Casing Specifications' 1-1 Domestic/Private ❑ Gravel Pack El Tracy yp g Type of Grout--- I`1 Public 171 Other 171 Delta Depth of Grout Seali h Irrtion -Approx Depth I I Eastern _Surface Seal Installed by iga tH P State Work Done Repair Work Done ❑ Type of Pump -Sealing Material itop 50'1 All Well Destruction ❑ Well Diameter , =r Depth Filler Material IBelow 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I.1 REPAIR/ADDITION l 1 DESTRUCTION I I aNailabptic systithin m rl etited if public sew er is Inst ' n will serve: Residence=._ Commercial— Other Number of liven Number of bedrooms Water table depth + Character of soil to a depth o iCapacity No. Compartments SEPTIC TANK ❑' Type/Mfg k PKG. TREATMENT PLT. ❑ Method of Disposal T r Pro drt Line Distance to nearest: Well Foun a p Y LEACHING LINE ❑/yNo. & Length of lines ✓� Total lengt FILTER BED LI to nearest: Well Foundation Property Line I' EEPAGE PITS i I Depth Size Number u ,-.-s I UMPS`P[ �,' n " L�~`Dista'r3ce ta,nearest "Well ` '"`:Foundation Property Line DISPOSAL*BONDS,. ❑ t�" -- z-1 Y f I hereby certifyfhaitgihave prepared-IN;"applicationSand 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. it is issued, I shall not :' Home owner or licensed agenVs.signature certifies'lhe.,following: "I certify that in the performance of the work for which this permsignature employ any person in such manner as to become•subjei: to workman's compensation laws of California." Contractor's ortobwo�kman''scampensa- i certifies the follpQwm'R: "I certify that in the.p; rformance o she work'fdrwhich this permit is issued,l shall employ psubject tion laws of.California.1' ---\ The applicant i all quired ' Complete drawing on reverse s' ' itle: Date: lQ-r Signed X ' FOR DEPARTMENT US ONLY Date_ ` V r Area Application Accepted by - I f Pit or Grout Inspection by �* Date Final Inspection by Date a Additional Comments: ❑ Stk 466-6781 L1Lod�369-3621 ❑ Manteca 823-7104 © Tracy 835-6385 Applicant - Return all cos•to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2005, Sik., CA 95201 CK RECEIVED BY DATE PERMIT NO. FEE AMOUNT DUE AMOUNT REMITTED GASH INFO EH 1324 IREV.t EH 1 4-2d 3�';