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APPLICATION FOR PERMIT SAN`moAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE i ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERM^:"T EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) itirztion is rdina ce No.549 for sewage or No. 1862 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' PP made in compliance with San J Uin County, 9 /� t, Local Health District. 8 c f`(�/ /V l/7�y"� _/ PM 111 City Lot Size Job Address _ Phone j _M Address r v f qw�� Name /— Phone / O IV e p License NO. 3b— E� A b>rj �i Address JVAQ/�/'170 1& Contractor�� WELL REPLACEMENT ❑ DESTRUCTION ❑ NE WELL OTHER ❑ TYPE OF WE INSTALLATION SYSTEM REPAIR ❑ PROP. LINE PUMP INSTALLATION El DISPOSAL FLD. SEWER LINES OTHER WELL PITS/SUMPS DISTANCE TO NEAREST: SEPTIC TANK AGRICULTURE WELL �— FOUNDATION ----- TYPE OF WELL PROBLEM CONSTRUCTION SPECIFICAjf10NS Dia. of Well Casing -_— INTENDED USE ❑ Manteca Dia. of Well Excavation .yt� ❑ Open Bottom Specifications�7T r ❑ Industrial ❑ Tracy Type of Casing �j Type of Grout� Domesti Gravel Pack 64 1A ❑ Public ❑ Other C3 Delta Depth of Grout Seal —�pprox. Depth ❑ Eastern Surface Seal Installed by ❑ Irrigation H P State Work Done K; ` Type of Pump h ��,y�./ 1u+161t Sew. Repair Work Done ❑ Sealing Material (top 50')&.11)4estrurtion ❑ Well Diameter _� r Mator!al (Below 50') _._at f low v available within 200 feet.) TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted i'i public sewer 1s Installation will serve: Residence Commercial_ Other Number of bedrooms Water table depth Number of !lulls units: — 6 Character of soil to a depth of 3 feet: _-- C No. Compartments —_---- SEPTIC TANK ❑ Type/Mfg Method of Disposal — PKG. TREATMENT PLT.❑ Foundation__ Property Line Distance to nearest: W —�— Total length/size_-- ❑ No. & of lines Property Line_-- LEACHING LINE Foundation_---- FILTER BED ❑ lance to nearest: Well---- .— Number ❑ Depth Size Property Line (1 SEEPAGE PIT Foundation_�— J•' SUMP ❑ Distance to nearest: Well_-- POSAL PONDS ❑ that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and I hereby certify t performance of the work for which this permit is issued, I shall not rules and regulations of the San Joaquin Local Health District. I certify that in the pe Home owner or licensed agent's signature certifies the following: " of Contractor's h subject to workman's compensa employ any person in such manner.as to become subject tthe work for wh ch thsation is permit issued!fl shall employ person hiring or sub-contracting signature certifies the following:"I certify that in the performance o tion laws of California." �� licant st call for all required ins ctions. Complete drawing on reverse side. Date: The app Title: � _ Signedf FOR DEPARTMENT USE ONLY / —iK < Date Area ll - Application Accepted by /� Dat atFinal Inspection by e De��' pit or Grout Inspection by Additional Comments: ❑ Manteca 823 7104 ❑ Tracy 83`x6385 tk CA 1 ❑ Stk 466-6781 ❑ Lodi 369-3621 Appl! nt _Return all�c/opties>�: Environmental Health Services 1601 E Hazelton Ave. P.O. Box 2009, r 7�S ,0.61 / �i�'' �" CK# RECEIVED BY DATE PERMIT NO. FEE AMOUNT DUE AMOUNT REMITTED CASH INFO — 1/,(� v� S5? -1-JL-As: . EH 13.24(REV. /e 5) EH 14-26