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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT / r 1601 E. HAZELTON AVE., STOCKTON, CA ( J Telephone (209) 466-6781 lyit PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (' �ic �L (Complete in Triplicate) J all the work . This Application is hereby made to the Sian Joaquin LocalHealth nce No.549 for sewage or cation is District for a PeINo. 1862 for t to cwell/PUMP and the Rules and 1R gulations of the Sanr Joaquin made in compliance with San Joaquin Local Health District. PM City Lot Size Job Address OPhone Address Owner's Name -I C- 0 �, 9 Mid� C- 0 License No.Q439M Phone_ Contractors 111»1��-' ddress - ;�) WELL REPLACEMENT ❑ DESTRUCTION ❑ TYPE OF WELL/PUMP: NEW WELL ❑_ SYSTEM REPAIR ❑ OTHER 11PUMP INSTALLATION C1 SEWER LINES __----- DISPOSAL FLD. POOP. LINE DISTANCE TO NEAREST: SEPTIC TANK OTHER WELL PITSISUMPS FOUNDATION AGRICULTURE WELL INTENDED USEM TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Specifications Type of Casing 13 Domestic/Private ❑ Gravel Pack" El Tracy Depth of Grout Seal Type of Grout i"1 Public ❑ Other f Ll Delta v _ Approx. Depth I 1 Eastern Surface Seal Installed by 00 H.P. I i Irrigation � State Work Done Repair Work Done ❑ Type of Pump ` Well Destruction ❑ Well Diameter Sealing Material atop 501 J� Depth Filler Material IBalow 50'I TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REf AIRIAQDITION LI' QESTRUCTION I available 20em 0 emitted if public sewer is O _Ad Installation will serve: Residence_ Commercial Other'" - { 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. ❑ r a Property Line i Distance to nearest: Wali Foundation Total length/size LEACHING LINE � ❑ No. f4 Length of lines Property Line FILTER BED ❑ Distance to nearest: Well" Foundation SEEPAGE PITS i I Depth Size Property Line SUMPS L-1 Distance to nearest: Well Foundation F P r•ty DISPOSAL PONDS ❑- 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, and rules and riegulations of the San Joaquin Local Health District. Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I 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 r certifies the followin I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- f3, tion laws of California." The applican ust call for all ui in ctions. late drawing o reverse de. ' Title: Date: Signed FOR DEPARTMENT USE ONLY �✓ ti Date ��'/ Area Application Accepted bDate ' z S.Lf�.� / Pit or Grout Inspection Date Final Inspection by Additional Comments: _ ❑ Stk 466 6781 ❑ Lodi 369-3621 0 Manta -7104 ❑ Tracy 835.6385 h Permit/Services s 1601 . Hazelton Ave., P.O. Box 2009,.Stk., CA 95261 Applicant - Return all copies to: Environmental Healt FEE AMOUNT RECEIVED BY DATE PERMIT'NO. INFO AMOUNt DUE AMOUNT REMITTED CASH P� y + EH 13-24 IaEV.1114 51 + EH 14-26 F