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)I APPLICATION FOR PERMIT " SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA y Telephone (209) 466-6181 {* 1 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED �`�-,, (Complete in Triplicate) n described.THS.appucation is Application is hereby made to the San Joan y Ordinance No.District Local Health 49 for sewage or11No. 1862 for well/pump and the t to construct a Ryles and nd/or install the work 1Regulations of the San Joaquin made in compliance with San Joaquin County Local Health District. PM �r City Lot Size Job Address Phone /1.fi1? Address t i Owner's Name G _ _ (� - f0 �`X70a Phone License - -•ContractDESTR f NEW WELL Q WELL REPLACEMENT ❑ UCTION ❑ TYPE OF WELL/PUMP' SYSTEM REPAIR LlOTHER Q 1 PUMP INSTALLATION E3 SEWER LINES _^� DISPOSAL FLD. 1 PROP_ LINE DISTANCE TO NEAREST: SEPTIC TANK OTHER WELL i PITSISUMPS `` FOUNDATION �_--- AGRICULTURE WELL Ii TION SPECIFICATIONS + y TYPE OF WELL PROBLEM AREA CONSTRUCTION f INTENDED USE l— :[ Dia. of Well Casing f Dia. of Well Excavation ; D Industrial ❑ Open Bottom ❑ Manteca Specifications ❑ Tracy Type of Casing ❑ DomesticIPrivate ❑ Gravel Pack❑ Other a Depth of Grout Seal �- f tType of Grout Ll ❑ Delt t Surface Seal Installed by` ' D Irrigation _—Approx. Depth El Eastern H P State Work Done Repair Work Done ❑ Type of Pump .. / Sealing Material (top 50'1 Well Destruction ❑ Well Diameter F' er Material (Below 50'1 .. ' Depth tic system permitted if public sewer is . TYPE OF SEPTIC WORK: NEW INALLATION ❑ REPAIR'ADDITION DESTRUCTIONaNailable`withiri 200 feet.) ki AY ` installation will serve: Residence zCornmercial_ Other � { Number of living units: Number of, edrooms „-�` '7tWater tabletdepth /d S Character of soil to a depth of 3 feet:/ Capacity No Compartments j SEPTIC TANK ❑ Type/Mfg +'��''� Method of &sposal # } ; l ' PKG. TREATMENT PLT. ❑ Foundation ' Property Line r�* Distance to nearest: Well � r t 'ii - Tata( length/size_ ' %'`^ ; L LEACHING LINE ❑ No. &Length of lines ., - ' "'•- �� ud F- Foundation Property Line FILTER BED ❑ Distance-to nearest: I Well r.- � -- rte.. Number�T SEEPAGE PITS I'Depth 4 Size , ❑ Distance to nearest: Well/Dom-Foundation d' "� Prape�tr y Lme S SUMPS [ 7. DISPOSAL PONDS ❑ I r i I hereby certify that I have prepared this application and"that�Fie work will-be done'i�accordance with San Joaquin county ordinances, state laws, an rules and regulations of the San Joaquin Local Health District, Home owner or licensed agent 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;n such manner as to become subject to workman's.i laws of California." Contractor's Miring or sub contracting signature i certifies the following:"1 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." The applicantjmust call for I required inspection.Complete drawing on reverse side. i Titlt �S :-•P* Date: ' - e: Y I Signed 1 h FOR DEPARTMENT USE ONLY f # Date .?- � >SArea l Application,Accepted by final�InpeGtla // on by i11 i' -P-it- r-Grout-inspection-by-- - E 1 Additional Comments: T ❑ Stk 466 6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104°, 1 Tracy 1 k Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., GA 95201 CK DATE PERMIT'NO. FEE CASH RECEIVED BY AMOUNT',DUE AMOUNT REMITTED INFO . .. +EH 13.24(REV. 1 s 51 LAS o a EH%26