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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA ^ Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) and/or install the work herein ation is hereby made to the San Joaquin Local Health District for a permit to construct n described. This application is unty Ordinance'nw 549 for sewage or No. 1862 for welllpump and the Rules and Regulation f the San made in compliance with San Joaquin CoJoaquin Applic Local Health District. 6eo,4� .3fl r r !/ y r Lot Size ._ PM �' s Jab Address ;/� � Cit ' '/ l Z�- , / �� / �Z/ 1�� Phone �. Owner's Name /�N� �� a _ (_!� Address i License No. Phone Address Contractor O WELL REPLACEMENT 1-1 DESTRUCTIO j TYPE OF ELL PUMP: NEW WELL-[ - 1 OER ❑ ! SYSTEM REPAIR ❑ PUMP INSTALLATION © � _4,1 .pROP. LINE SEWER LINES DISPOSAL FLD. f' DISTANCE TO NEAREST: SEPTIC TANK OTHER WELL ° PITS/SUMPS FOUNDATION AGRICULTURE WELL - —- INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing ❑ industrial ❑`.Open Bottom ❑ Manteca Dia. of Weil Excavation Specifications '"' ` ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing -- Cl Other ❑ Delta �,y�Depth.of Grout Seal �`.T~ Type of Grout P Public - I I irrigation �':AppRo Depth l I Eastern Surface Seal Installed by- I 1F i State Work Done Repair Work Done F] Type of PUmp', H.P. Sealin Material Imp 50'1 i ' Well Destru_c_tion ❑ Well Diameter g :�, ,,, g —Depth Filler Matenal (Below 50'1 TYPE OF SEPTIC WORK: tNEW INSTALLATION 11 REPAIRlADDITION DESTRUCTION l 1 availablelc system wthin 200 feet.) if public sewer is t � Installation will serve: Residence.� Commercial_ Other Number of living;units: Number of bedlpefns i 4 �© "` Water table depth Character of soil to-a depth of-3 feet: i + r Capacity , No. Compartments SEPTIC;TANK ❑: Type/Mfg �- � �O Method of is�osal_ PKG. TREATMENT PLT. ❑ r ti / Property Line = _ Distance to nearest: Well 411 ! ``Foundation - � may. �'"" }—.. fin► � .. l r. g Tgtal length/size Len a r LEACHING LINE Length of lines �L Distance to nearest: Well Foundation V -"'Property Line r t ` FILTER BED S SEEPAGE PITS l l Depth I iSize £r + Naber `40undation Property Line SUMPS Cl Distatnce to nearest: Well_ DISPOSAL PONDS ❑ i 1 hereby certify'that I have prepared this application acid that the work will be done,in accordance with San Joaquin county ordinances,s a laws, and rules and regulations of the San Joaquin Local Healt!N�District. "�. ""' ti 3 L; Home owner or licensed agent's signature certifies theafollowing: "I certify that in the performance of the work for which this permit is issued, l shall not employ any person signature in,such manner as to become subject to workman's compensation laws of Califorriia." Contractor's nsrring sub'ect to woorkmanlscompensa- certifies the folio ing:'r"I certify that in the performance of the work for which this permit is issued, i shallrerrlploy p 1 tion laws of C o nia." { r or all quired inspections. Complete drawing on rev side- The applica t fK_ Date: Signed X ? Title: OR DEPARTME�TUSE�( NLY Date Area Le — t Application Accepted by Rate Final Inspection byDa Pit or Grout Inspection by w..-- " f �. k Additional Comments: ice. 835-6385 ElStk, ❑�466•6781 ❑ Lodi 369-3621 "� Manteca 823 7104- ❑ Trac Y ¢ Applicant-`Return all copies to: Environmek tal Heatthl'Permt/Services t601�E. Hazelton Ave., P.O. Bax 2009, Stk., CA 95201 k ` C RECEIVED BY DATE PERMIT NO. FEE INFO AMOUNT DUE AMOUNT REMITTED + EH 13-24 4REV.I EH 14-29 ate"