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APPLIC TION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE k T ON AVE., STOCKTON, CASPiN JOAQUIN LOCAL HEALTH 61STRICT ENVfRONMENTAL HEALTH DIVISION Telephone (209) 466-67$1' SPECOA ' PERMIT PERMIT EXPIRES 1 YEAR FROM DATE ISSUED .i F ��l r1 i (Complete in Triplicate) � evZ l lth District for a Permit to construct and/or install the work herein described.This application is Application is hereby made to the San Joaquin Local Hea . 549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin made in compliance with San Joaquin County Ordinance No ' Local Health District. PM City Lot Size AdrssJob � TI S•t'.. �1[�teutai 4 Phone Addressi Z Owner's Name License No.`-y'66 7a Phone � 7 Contractorb 6�S� � t��,�,,.4 Address TYPE OF WELL/PUMP: v NEW WELL WELL REPLACEMENT ❑ DESTRUCTION El SYSTEM REPAIR ❑ OTHER ❑ PUMP INSTALLATION ❑ /aa r DISTANCE TO NEAREST: SEPTIC TANK "~ SEWER LINES _ G� DISPOSAL FLD. PROP. LINE — FOUNDATION 2Z: AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM ARI CONSTRUCTION SPECIFICATIONS � �.�, Dia. of Well Casing `la ❑ Industrial • ❑ Open Bottom ❑ Manteca Dia. of^Well Excavation Specifications r Type of Casing w © RomesticlPrivate Gravel Pack El Tracy l tom . Type of Grout_- i ❑ Delta i Depth of Grout Seal — f'1 Public ❑ Qther I Irf�t atian .Approx. Depth I 1 Eastern Surface Sea! Installed by X fN !•�44144 H L-1P� State Work Done_ Repair Work Done Type of Pump Well Destruction ❑ Well Diameter Sealing Material (top 50'1 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I.i REPAIR,'/ADDITION l 1 DESTRUCTION I i INo availablelc system wi within 200 feetit�ed if public sewer is � €p Y Q Installation will serve: Residences Commercial— Other Number of living units: Number of bedrooms I Water table depth Character of soil to a depth of 3 feet: r SEPTIC TANK ❑ Type/Mfg 'I Capacity Qtp@5j►]�enjt; i fis a al F PKG. TREATMENT PLT. ❑ ,�` `Pro erty Line f Distance to nearest: Well Foundation pp To I-length/size LEACHING LINE ❑ No. & Length of lines tfVEl��r��<< ❑ Distance to nearest: Well l Foundation roper;+r L?rref , - FILTER BED bavu J I SEEPAGE PITS I I Depth Size Number � SUMPS L� Distance to nearest: Well I Foundation Property Line' ; DISPOSAL PONDS ❑ ' j thereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and 1 rules and regulations of the San Joaquin Local Health District: Mame owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, 1 shall not employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the followin I certify that in the rformance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- g: ' Pe tion laws of California." The applicant must call for all required inspections. Complete drawing on66 Date: reverse side. lain t' Signed X { FOR PARTMENT USE ONLY �f p � .Date Application Accepted by /�_ •, Date Final lnspection by Date Pit or Grout Inspection by l E Additional Comments: ❑ Stk 466-6781 0 Lodi 369-3621 ❑ Manteca; 823-7144 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.Q. Box 2009, Stk., CA 95291 FEE AMOUNT DUE AMOUNT REMITTED C RECEIVED BY BATE PERMIT NO. INFO r + EH 13-24 4REV.t - �•"'s^' r +'' 4 EH 14-26 l�