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k APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT -1601 E. HAZELTON AVE., STOCKTON, CA I Telephone (209) 466-6781, <� PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ' (Complete in Triplicate) Application is hereby made to the Sari Joaquin Local Health District for a made in compliance with San Joaquin:County Ordinance No.549 for sewage or No. 1862 forrmit to const, cwell/dpump Install the Rules and Regulations of the San Joaquin Local Health District. the work application is ]AM Navy Drive; b Job Address t Stockton �t _ 'City Lot Size Owner's Name Ci3rnation Can. PM Address 1915 NaV Drive:=} Ai 1 Terrain Phone 466-7077 Coritractor_`EXpjoration & �Jress 2789 Li.bert �n ROs TYPE OF evi i.];eense No.437836 6 f WELL/PUMP:.. NEW WELL L ---�Phone771-0222 WELL REPLACEMENT LD DESTRUCTION ' PUMP INSTALLATION ❑ DISTANCE TO NEAREST: SEPTIC TANK SYSTEM REPAIR ❑ OTHER SEW ER LINES DISPOSAL FLD. FOUNDATION AGRICULTURE WELL PROP. LINE OTHER WELL-- PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFIC TIONS ❑ Industrial ❑ Open Bottom ❑ Man �a Dia. of Well Exc�i.lton 2 inch ' Domestic/Private Gravel Pack El Tracy T i.1r11 Dia: of Well Casing ❑ Public Type of Casing El Other. ❑ Delta e Depth of Grout Sea! 20 f, Specifications peoGru ❑ irrigation 25 pprox. Depth ❑ Eastern Type of Grout ,t Repair Work Done ❑ Type of Pum Surface Seal Installed by P � H.P. State Work Done 1 Well Destruction ❑ Well Diameter Sealing Material (lop 50') Depth Filler Mateiial (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system Installation will serve: Residence Permitted if public sewer is # Commercial_ available within 200 feet.) M1 ), Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet:Ix l' + SEPTIC TANK ❑ Type/Mfg)# Water table depth PKG. TREATMENT PLT. ❑ l Capacity No. Compartments Distance to nearest: Well Method of Disposal + Foundation�� Property Line LEACHING LINE �� Q No. & Length of lines ' FILTER BED Total length/size i ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth 1 SUMPS Size i` Number ❑ Distance to nearest: Well DISPOSAL PONDS " C7 ° .n Foundation_ Property Line = �.- 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, ar' rules and regulations of the San Joaquin Local Health District. i ! Home owner or licensed agent's signature cert Pies the following: "I certify that in the performance of the work for which this ! not employ any person in such manner as to become subject to workman's compensation certifies the following: Pehis pen laws ss California."Contractor's hiring oPsub-contracting lsignashalf tura T tion laws of California." cr—fy that in the Performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- The appl' nt m st call f all requir nspections. Complete drawing on reverse side. ; "# Signed �. } Title: Date: �R FOR DEPARTMENT USE ONLY Application Accepted y ' 7 Date r Pit or Grout Inspection b _.� a Date lnal Inspection b Additional comments: Date_IL:i ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Applicant- Return all copies to: Environmental Health aPerm t/Sntecaerery ces 1601 E❑Hazehon Am p O Box 2009, Stk., CA 95201 t.l ;1 FEE AMOUNT DUE t INFO AMOUNT REMITTED RECEIVED 11Y CASH DATE EH PERMIT'N0. 1 + 13-24 fREV.1/957 a r1 :::: ^7EH 1428 U � 1— /47 .. —/