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' APPLICATION FOR PERMIT y SAN JOAQUIN LOCAL HEALTH DISTRICT ' 1601 E. HAZELTON AVE., STOCKTON, CA Telephone 1209) 466-6781 d PERMIT EXPIRES 1'YEAR FROM DATE ISSUED ' (Complete in Triplicate) made nticompliance with SanoJoags nncounty Ordinauin lnce No.Districtealth 549 for sewage ortlt to No. 1862 forcwell/dpump install nd the Rules and herein Regulations of trhe Sancation is Joaquin ' Local Health District. r - A p PM ��46� � mom=�7�'. • � City /y-- Lot Size Job Address CAS*WA, X4XkC-E b.0 Phone ne Owr's Name GRAAlS/-z' A 41AF Address . FLOYh� M/nmA � Address'.7 �• ADE4.,dE.BT S. r License No,4�2q Phone y�397 Contractor L. ' TYPE OF WELL/PUMP: NEW WELL ❑ WELL'AEPLACEMENT ❑ DESTRUCTION ❑ t ` T-�- `N </ 'il f IASYSTEM REPAIR ❑ OTHER ❑ W PUMP INSTALLATION N, PROP. LINE DISTANCE TO NEAREST: SEPTIC TANK - SEWER LINES FCD. - p{ o\ AGRICULTURE WELL OTHER WELL PITS/SUMPS ' FOUNDATION { INTENDED USE TYPE OF WELL? PROBLEM AREA TRUCTION SPECIFICATIONS Dia. of Well Casing El Industrial ❑ Open Bottom 1 ❑ Mantec Dia. of Well Excavatipn ' py Type of Casing Specifications'- ❑ Domestic/Private ❑ Gravel Pack ` Depth of Grout Seal , "'k Type of Grout ❑ Public ❑ Other r ❑ 061ta I I Irrigation _n-APPr . Depth I I Eastern Surface Seal"Installed by If um I I H.P. State Work Done— e ' Repair Work Done C3Type P I Well Destruction ❑ Well Diameter Sealing Material (top-50'I r Depth I Filler Material (Below 501 1 TYPE OF SEPTIC WORK: NEW INSTALLATION L1 REPAIR/ADDITION N DESTRUCTION i I available)within 200 feetitted it public sewer is Installation will serve: Residence Commercial_ Other 1 Number of living units:—I-- Number o'fsbedrooms 2/ i Water table depth Character of soil to a depth of 3 feet: No. Compartments SEPTIC Tq5TANK ❑ ' Type/Mfg ' tr t '^ 'Capacity ' Method of Disposal C3 '! PKG. TREATMENT PLT. JgDistance to nearest: Rt Well Foundatidn Property,Line LEACHING LINE LNC No. & Length of line 42 Total length/size Distance to neatest: y� rest�� FILTER BED � ❑ 1 atest: Well SO r Foundation Ad r Property Line _ B { A ' SEEPAGE PITS I'I h Depth �y r Size 1Z' X l O Number , I O 7.B Proper,,Line SUMPS ,K Distance to nearest: Well O foundation _ DISPOSAL PONDS 0 i - - I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin ebunty ordina"lIces, state laws, and. rules and regulations of the San Joaquin Local Health District:, "1 certify that in the performance of the work for which this permit k issued, I shall not,; Home owner or licensed agent's signature certifies the following: 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." i� The applicant must call for all required inspec'ons. Complete drawing on reverse side. ' D I -2,/ `Date: 1; Signed X9a Title: f O\e�ii, FOR DEPARTMENT USE ONLY Application Accepted by \nw e .! Date .Area ' Date Final Inspection by Date Pit or Grout Inspection by l� p / t� 1177 I /.2C 8'9'r Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 623-7104 ❑ Tracy 835-6385 ' Applicant• Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 pK, � 1 FEE UK RECEIVED BY DATE PERMIT NO. AMOUNT DUE AMOUNT REMITTED CASH ' INFO r.EN 13-24 tRF9.1 10