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• '.-� APPLICATION FOR PERMIT ? SAN JOAQUIN LOCAL"HEALTH DISTRICT I 1601 E. HAZELTON AVE., STOCKTON, CA = Telephone (209) 466-6781' PERMIT EXPIRES 1"YEAR FROM DATE ISSUED i (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct i I th work herein described. This application is o. 1862 for weell!lil made in compliance with San Joaquin County Ordinance No.549 for sewage or Np and the Rules and Regulations of the San Joaquin Local Health District. I" 2 CdrU e r .e��PM city , ►Lot"Size Job Address Address Phone Owner's Name j ho Address 1, � - License No. Contractor +� TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ . Ar I PUMP INSTALLATION C3 SYSTEM REPAIR O, OTHER ❑ SEWER LINES DISPOSAL FLD. PROP. LINE DISTANCE TO NEAREST: SEPTIC TANK FOUNDATION AGRICULTURE WELL 'OTHER WELL PITS/SUMPS INTENDff)TUSE.`r TYPE OF-WELL--PROBEEM A'REA--^�^CONST"RUCTION SPECIFICATIONS-.� - DI---^�Well Casing ❑ Industrial Ll open Bottom ❑ Manteca Dia. of Well Excavation T e of Casing Specifications y ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Yp4; —, ` F1 Delta .-r Depthrof Grout Seal Type of Grout 171 Public F1 Other '�,7";� ' I I irrigation ..Approx. Depth i I ! Eastern, ;surface Seal Installed by IH P State Work Done _ Repair Work Done El Type of Pump , t r S Sealing Material (top 50'1 Well Destruction ❑ Well Diameter Filler Material (Below 501 Depth e TYPE OF SEPTIC WORK: - NEW INSTALLATION I REPAIRIADDITIOIV I I DESTRUCTION l ! availablerwi hin 200 feetsystem r.)ed it public sewer is , Installation will serve: Residence Commercial Other Number of.living..units: Number of bedrooms l` _ �++ . �, �� ".. � Water table depth Character of soil.ta a depth of 3'feet: � s r ��Capacity " = f No. Compartments SEPTIC TANK "'� ❑ {Type.,.fg _(2 2 t Method of Disposal -PKG. TREATMENT PLT. ❑ 111. / ! "Distance to nearest: Well �Fou7idation�.�— ='Property Line Total length/size LEACHING LINE ❑ No. & Length of lines `FILTER SEED Foundation` - Property Line ❑ Distance to nearest: Well"1f1� .� TSEEPAGE PISS - I h: Siie; umber, ;.• h�- f SUMPS LlDistanceto nearest: ~Well --Foundations Property Line- Ik DISPOSAL PONDS p �� _. ':'"�''w+e�".. '�.'.� •r > r d that the work will be done in accordance with San Joaquin c unty ordinances,estate laws, and I hereby certify that l have prepared this application an rules and regulations of the San Joaquin"Local Health District: k '1 ce0'tify that in the performance of the work for which this Home owner or licensed agent's signature certifies the following: permit is issued; I shall not employ>any person in such manner as to became subject to workman's cortnpensation,laws of California."Contractor's hiringforsub-contracting signature,, certifies the fallowing: "I certify that in tF1e performance of the work for which this permit is issued,I shall employ persons subject-to workman's compensa tion laws of California." ". 10'ti - s` The applicant m s all fol a requ rn _ ns- Complete drawing on reverse side. . I Signed X � itle: 4-- i f =.a FOR DEPARTMENT USE ONLY. V E Area Application Accepted by Date - -.0 Dat-42�� Final Inspection by i .1 PiYor Grout Inspection by I , Additional Comments: 835-6385❑ Stk 466-6781 EI Lodi 369-3621 Y X❑ Manteca"823-7104 ❑.Tracy; Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave.,P.OBo2009.IStk., CA 45201 FEE RECEIVED 8Y DATE PERMIT NO. AMOUNT DUE AMOUNT REMITTED INFO r"EH 13-24{REV:r 19 51 � X�Q 1 p > EH 1628 _ .. . i' F .. -,