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APPLICATION TOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE.,,STOCKTON, CA k -Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ' (Complete in Triplicate) roc,IL Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. TMs application is f made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin .y.. Local Health District.'t w f +. t t: Nle City Lot Size GtC. PM Job Address nn ` Phone I Owner's Names rV-��- Address _ # License No.e�3�4 S a 03 Phone a�-�7� Contr`acto � ~ '4 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ w PUMP, INSTALLATION 1-1SYSTEM REPAIR ❑ # OTHER ❑• b ISEWER LINES DISPOSAL FL-D. - PROP. LINE DISTANCE TO NEAREST: SEPTIC TANK r } `. PITS/SUMPS_ FOUNDATION AGRICULTURE WELL OTHER,WELL INTENDED USE TYPE OF'WELL PROBLEM�AREA CONSTRUCTION SPECIFICATIONS . .. w , .v ." .� ❑ Open Bottom E ❑ Manteca Dia. of Well Excavation Dia. of WeiL.Casing ❑ Industrial 1 T of Casing Specifications �x ' ❑ Domestic/Private El Gravel Pack �❑ Tracy Type 9 h ❑ Other _a❑ Dekta_ Depth of Grout Seal Type of Grout [ ❑ Public ; ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by I, State.Work Done ' Repair Work Done ❑ Type of Pump H.P. IF Sealing Material Ito 50'1 Weil Destruction ❑ Well Diameter 9 p `r -• - Depth Filler Material {Below 501 TYPE OF SEPTIC,WORK: NEW IN'T ALLATION f REPAIR IADDITION DESTRUCTION ❑-'(No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial Other Number of living units: Number of bedrooms IV-- _ Water table depth Character of soil to a depth of 3 feet: SEPTIC TANK ❑ Type/Mfg S Capacity- O v No. Compartments Method of Disposal PKG. TREATMENT.PLT. ❑ / a ; - a F Distance to nearest: WI^ Foundation Properl'y''Cine,� u = r . r }T :; LEACHING LINE NE" No.No. &Length of lines Tot1 1.al length/size ter! i i' Q_! Foundations Property LineZO_ FILTER BED �- ❑ Distance to nearest: SEEPAGE PITS ❑ epth Number- ` " Property SUMPS ❑ !iis nearest: Well Foundation �. ! DISPOSAL PONDS ❑ this application and that the.work will be done in accordance with San Joaquin county ordinances, state laws, and V I hereby certify that I have prepared p , • rules and regulations 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 certifies the following:"I certify that in the performance of the work for which this permit is issued,I shall employ persons subject to workman's compensa- tion laws of California.". 1 f The applicant mu COfor all required inspections. Complete drawing on reverse si^de:_ J Signed X Title: Date: Si r 9 _ r FOR DEPARTMENT USE ONLY /- i. Date d Area ' Application Accepted by -- Pit or Grout Inspection by Date Final Inspection by I Additional Comments: ❑ Stk 466-6781 El Lodi 369-3621 [1 Manteca 823-7104 Ll Tracy 635 6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2OD9, Stk., CA 95201 FEE CK ERFCEIVED BY DATE PERMIT'NO. INFO AMOUNT DUE AMOUNT REMITTED CASH ^f U2f�� _ ':;EH 13241REV.-1/951 0, 1Vv EH 1428