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APPLICATION FOR PERMIT "� SAN JOAQUIN LOCAL HEALTH DISTRICT t 1601 E. HAZEL T ON AVE., STOCKTON, CA Al Telephone (209) 466-6781 NNE AL��pSLZ I PERMIT EXPIRES TYEAR FROM DATE ISSUED MIT19 I q {Complete iri Triplicatel, t%l �Q / 7�� Application is hereby made to She San Joaquin Local Health District for a permit to construct and/or insta t e work herein describe sap ca ion is made in compliance with San Joaquin County Ordinance No.$49 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. �( 2,g°� �" {c4,d�vC�,(- G- J I7 ,/Ji � ,�/� �.L If/F_ ��/r✓ffff f�/U/ /��Sr f�� Civ Lot Size PM Job Address` ; '.,. U� > h T Z �'"' Address Phone Owner's Name _ J r FGTl2 �� Phone Contract �� lrlrt Address l.iCense Noe TYPE OF WELLIPUMP: NEW WEL WELL REPLACEMENT ❑ DESTRUCTION ❑ i -PUMP 1NSTALLATION� SYSTEM REPAIR'❑ OTHER,[] • DISPOSAL FLD. POOP. LINE _ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES FOUNDATION AGRICULTURE WELL — OTRER WELL "PITSlSUMPS INTENDED USE TYPE OF WELL PROBLEM AREA s CONSTRUCTION SPECIFICATIONSDia of"Well, Casing ll� ❑ industrial ��en Bottom ❑ Manteca Dia.-of Well Excavation A. y �} . 1�.�+ S eclfications mestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing �fJ p f { C] Other Cl Delta Depth of Grout Seal Type of Grout - (-1 Public rngatian —Approx. Depth I I Eastern Waco Seal Installed by Repair Work Done ❑ Type of Pump H.P. state Work Done '.1 Sealing Material (top 50'1 Well Destruction- -❑' Well Diameter 9 i n Depth Filler Material (Below.501 ' I TYPE OF.SEPTIC WORK: NEW INSTALLATION 1.1 . REPAIRIADDITION I I DESTRUCTION 1 I Mo septic system permitted ifjpublic sewer is T T d available within 200 feet.) Installation will serve: Residence Commercial— Other Number of living units: Number of bedroomsWater table I.depth Character of sail to a depth of feet: - Y 3 SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments' = A Method of Disposal PKG. TREATMENT PLT. ❑ 1f r Distr ance to nearest: Well Foundation Property Line � LEACHING LINE Cl Total length/size No. & Length of lines - FILTER BED ,. ❑ Distance to nearest: Well Foundation Property Line 4 SEEPAGE PITS I I Depth f Size Number SUMPS Ll - Distance to nearest:- -• Well Foundation Property Line DISPOSAL PONDS ❑ I hnrcby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health Di§trict. - Home owner or licensed agent's signature certifies the following: "I certify that in the`porformance of the work for which this permit is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's shin e r t workmancompensa- ture certifies the following: "I certify that in the performance of the work for which this permit is issued,I shall employ p 1 _ tion laws of California." �. - a The applicant m t call for all required inspections. Complete drawing on,reverse side. ! �!'�/ ';; %%:�, Bate: /'.�G Title: Signed X FOR DEPARTMENT USE ONLY ' Date �'U Area _ _ — Application Accepted by �!� 0 Date�/ Final Inspection by tpate� i -Pit or Grout Inspection by yLl Additional Comments: _ ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 - 0 Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 h FEECK RECEIVED 9Y DATE ' 'PERMIT"NO. AMOUNT DUE AMOUNT REMITTED CA H / INFO.. -pl6 - - • EH 13"24 iREV.>>nsi EH 14-28 > / - t