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APPLICATION FOR PERMIT SAN JOAQUINI1.LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRESHI YEAR FROM DATE ISSUED (Col�plete in Triplicate) application is 549 for sewage or No. tB62 for well/pump and the Rules and Regulations of the San Joaquin Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This app made in compliance with San Joaquin Co linty Ordinance No. Local Health District. City 7 r — Lot Size PM {P Job Address 1L? ,7- Sal D S. Address: Phone , _ Owner's Name # t I License No. Phone Address— ]I Contractor WELL REPLACEMENT ❑ DESTRUCTION ❑ TYPE OF WELL/PUMP: NEW WELL ❑ OTHER ❑ �n� PUMP INSTALLATION SYSTEM REPAIR ❑ / SEWER LINES DISPOSAL FLD. PROP. LINE DISTANCE TO NEAREST: SEPTIC TANK OTHER WELL PITS/SUMPS FOUNDATION AGRICULTURE WELL INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing El Industrial Ll Open Bottom ❑ Manteca Dia. of Well Excavation Specifications h ❑ Trac Type of Casing Private ❑ Gravel P I k y Depth of Grout Seal Type of Grout---- Domestic/ j ll Other CI Delta (I Public , i S rf ce se,I I tailed by I I Irrigation ..Approx. Depth l l Eastern State Work Done H.i. Repair Work Done ❑ Type of Pump ---- 5esling Material (top 50')e 0 �• Well Destruction ❑ Well Diameter pe Depth Filler Materia! (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I l REI AIR''/ADDITION l 1 DESTRUCTION l 1 availabNo peNo lwi within 200 tec system at')ed if public sewer is installation will serve: Residence Commercial they Number of living units: Number of bedrooms Water table depth Character of soil to a depth of 3 feet: Capacity No. Compartments SEPTIC TANK ❑ Type/Mfg Method of Disposal PKG. TREATMENT PLT. ❑ Foundation Property.Line Distance to nearest: Well M Total length size LEACHING LINE C1 No. &Length of lines _ property Line s FILTER BED ❑ Distari� to nearest: Well �, Foundation Size M Number SEEPAGE PITS I ! Depth Property Line SUMPS Ll Distance to nearest-. ell ` Foundation DISPOSAL PONDS ❑ 9 I I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, stale laws, and rules and regulations of the San Joaquin Local Health Diltrict. work for this permit is l Home owner or licensed cagent's emanner as ture certifies to become subject wogrkman'srtcompensation Iify that in the aewsoomCafiforniahe Contractor's jhiring or sub-contracting l signature tof 1 employ any person certifies the followin :"I certify that in the performance of thework for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of Calif`rnia." Tfi an call for all re uired i spections. Complet (drawing on reverse side. ) �' Title: Date: C Signed X i IF R DEPA FMIENT USE ONLY _ _ Date Area Application Accepte by7 J Final Inspection D Pit or Grout lnspe tion by Date by ate ,—�-- _ a� Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca` 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Formit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 i PERMIT NO. F FEE AMOUNT REMITTED RECEIVED BY DATE AMOUNT DUE „ C H INFO `' NN p v/S7 +.EH 13.24(REV.1/n 51 f S7 C 1 EH 14-28