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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466 6781 PERMIT EXPIRES-TYEAR FROM DATE ISSUED (Complete in Triplicate) . This cation is Application 1lance with Sanothe San Joaqu n County OrdinaLocal nce No. 549 for sewage or permit No. 1862 for cwelllpu and/or install the R l s and Regulations of he San Joaquin made P Local Health District. 2, City Lot Size M Job Address / 0 Phone /—2 Owner's Name Address . ��-.--- '7 �—mar--•vfl�I�L.S � �, r • ddress 4 License No. Phone Conkraclor� WELL REPLACEMENT ❑ DESTRUCTION`0 TYPE OF WELL/PUMP: NEW LL Ll OTHER ❑ r PUMP INSTALLATION LJ SYSTEM REPAIR L] " SEWER LINES DISPOSAL FLD. PROP. LINE DISTANCE TO NEAREST: SEPTIC TANK _ .. �� ---- FOUNDATION AGRICULTURE WELL t OTHER WELL— TYPE s INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS pia. of Well Casing } ❑ Industrial ❑ Open Bottom ❑ Manteca - Dia.,of,Well Excavation ` Type of Casing Specific�Grouttions + ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy T e of l Public f Other C Delta Depth of Grout Seal Type A Depth l I Eastern„ ,,,,,". Surface Seal Installed,by 'k I I Irrigation � - —.-Approx. p r Repair Work Done ❑ Type of Pump H P Ste Work Done Sealing Material Itop 50'1 ' ' - Well Destruction ❑ Well Diameter 9 { Depth Filler Material l8elow 501 TYPE OF SEPTIC WORK: NEW INSTALLATION l REPAIRlAQDITION l I DESTRUCTION l I aNailabpelwthin 200 feet.) if public sewer is � { ` Installation will serve: Residence Commercial___Other. r Number M-living units: Number of bedrooms ter tabdepth I Character of soil to a depth of 3 feet: Wale t fi a_ ' ~Capacity No. Compartments SEPTIC TANK ElType/Mfg i ' PKG. TREATMENT PLT. ❑ 1 Method of Di�pos , t u 6 Distance to nearest:' Well Il) Foundation, ,PfoPerty Line f To�l lengthlsize J F 4LEACHING LINE ❑ No. & Length of lines f 'FILTER BED ❑ Distance to nearest: We I Fou dati& Pioperty Line r f +, _ Number r SEEPAGE PITS �,.•" i I Depth Size " 4 rSUMPS L-I Distance to near st: Well'��.f � � Foundation Property Line t „ ,t �?yrJ P !`DISPOSAL PONDS ❑- laws, and =r hereby certify that I have piepared'this application and that the work will be done in accordance with San Joaquin county ordinances, state i rules and.regulations of the San Joaquin Local HealthDistrict. l certify that in the performance of the work for which this permit is issued, 1 shah not Home owner or licensed agent's signature certifies the following: "I i `employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's,hiring or sub-contracting signature r 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." f 'The applicant st call for quired ins ctions. Complete drawing on reverse side. ' kt Signed Title: �._�e[Q An Ae:3 i Date: FOR DEPARTMENT USE ONLY Date Area Application Accepted by _ - � � ' k pat Final Inspection by Date Pit or Grout Inspection by Additional Comments: _ f ❑ Silk 466-6781 Q Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835 6385 rt, k Applicant Return all-copies to: Environmental Health Permit/Services 1601 E. Hazalton Ave., P.O. Box 2009, Stk., CA 95201 } FEE CK RECEIVED 8Y DATE PERMIT NO. AMOUNT DUE AMOUNT REMITTED CASH INFO r r.EH 13.24(REV.I/R 5) EH 14-26 L - -