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I APPLICATION FOR PERMIT fl SAN JOAQUIN LOCAL HEALTH DISTRICT #I 1GOf E. HAZEL T ON AVE., STOCKTON, CA { Telephtirit; (209) 466.6781 0 PERMIT EXPIRES 1'YEAR FROM DATE ISSUED FILE p Y (Complete in Triplicate) Application is heieblance made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application made H 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 Local Health Distrirc�t.�7 is Job Address � /"G City Lot Sira� f . (? ./ Owner's Name PM Z�'r ,.6�� Address Phone. Contractor 3 �; Address y� �� TYPE OF WELL/PUMP: NEW WELL El No._�-��Phone PUMP INSTALLATION ❑ WELL REPLACEMENT 0 DESTRUCTIO DISTANCE TO NEAREST: SEPTIC TANKSYSTEM REPAIR LlOTHER El SEWER LINES —_ . DISPOSAL FLD. FOUNDATION AGRICULTURE WELL PROP' LINE INTENDED USE OTHER WELL PITS/SUMPS Q TYPE OF WELL PROBLEM AREA CONSTRUCTfON SPECIFICATIONS Industrial El Open Bottom D Manteca Dia. of Well Excavation Cl Domestic/Private ❑ Gravel Pack ��,r�. � Dia. of Well Casing f i Publicr racy Type of Casing f--1 Olp6r VSpecifications I ! Irrigation C7 Delta Depth of Grout Seal " /3 ,3:1-Approx. Depthi I Eastern Type of Grout Repair Work Done D Type of Surface Seal Installed by I Pump Well Destruction ❑ H.P, State Wor 'Done r� Well Diameter �— Sealing Material {top 50.1 TYPE P Depth Filler Material {Below 50'1 p OF SEPTIC WORK: NEW INSTAL 'IV t'A REPAIR/ADDITION I DESTRUCTION f I (No septic system permitted it ublic Installation will serve: ResidenceCommercial_ Other available within 200 feet.) P sewer is �` , _�� _ y.J Number of living units:' Number of bedrooms Character of soil to a depth of 3 feet: SEPTIC TANK ❑ Type/Mfg Water table depth PKG. TREATMENT PLT. ❑ Capacity � No. Compartments Distance to nearest: WellMethod of Disposal { Foundation ProPerty line LEACHING LINE "` ❑ No!& Length of lines V" I FILTER BED C1 Distance to nearest: WeilTotal length/size Foundation�_-Property Line SEEPAGE PITS I I 'Depth SUMPS . Sire Number L7 Distance to nearest: Well ' DISPOSAL PONDS ❑ 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 rules and regulations of the San Joaquin Local Health Di?;trict. Home owner or licensed agent's signature certifies the following: to laws, and employ any person in such manner as to became subject to workman'srtcompensn the laws of mance of the Contractor's work for which opsub-co issued I shall not certifies the following:"I certify that in the performance of the work for which this permit is issued,I shall employ tion laws of following: p acting signature P Y Persons subject to workman's compensa- tion applicant usipcald ctians. Complete drawing on reverse side. Signed X Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by - Pit or Grout Inspection by Date Firla Ins Are ction Dateby Additional Comments: I Date ElStk 466-6781 _Z�;; a , ❑ Lodi 369-3621 ❑ Mar, ca 823-7104Q/P✓ 5-6385 Applicant - Return all copies to: Environmental Health permit/Services 1601 E. Tracy.❑Hazelt n 3Ave_ P.O. Box 2009, Stk., CA 95201 FEE UE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY �y� CASH DATE PERMIT"N0. :.EH 13-21IAEV.1ix57 "Xy�.v"' GH 11-26 �� 5—"