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E. 4 APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE-,TON AVE., STOCKTON, CA Telephone (209) 466-6781 .. .. . Y - PERMIT EXPIRES`? YEAR FROM DATE ISSUED (Complete in,Triplicate) 1i3�'. p,. 3 .. ,,.t, , ,. work herein application is perm �tfS Application is hereby made to the San Joaquin OLocanHealth ce No.District49 for sewage or it to 1862for t construct and/or install and the Rulsand Regulations of he San Joaquin made in compliance with San Joaquin County ". } Local Health District. r, .,au.0 Y b g-� f' 5�G Lot Size �O PM f �L I�Y11'�'Sz= � ' ,City- Job Address s - f ``lld Phone Owner's Name q - OM f V Address UA 2—C S T, ZPhoneQtf�3 5 ,3 �f. Address jC?O.C> �� license No. Contractor — . WELL-REPLACEMENT ❑ DESTRUCTION ❑ TYPE OF WELL/PUMP: - NEW WELL ❑ '<,r�� ,�,�;.,,-,.,„ ------OTHER T❑ �T..-wPUMP-INSTALLATION-�—»�—•-� "- SYSTEM-REPAIRQ _SEWER LINES � DISPOSAL FLD. PROP. LINE I DISTANCE TO NEAREST: SEPTIC TANK - PITSLSU FOUNDATION. AGRICULTURE WELL OTHER WELL �f l TYPE OF WELL PflOBL""EIIAAREA CONSTRUCTION SPE T i l INTENDED —�:�� xcavation Dia- of Well Casing ❑ Open Bottom ❑ Manteca' ' L ❑ Industrial l '` Type Te of Casing Specifications ❑ Domestic/Priv ate ❑ Gravel Pack '; Type of iGrout ❑ Other ❑ Delta I Depth of Grout Seal ❑ Public Surface Seal Installed by I } �0.pprox. Depth ❑.Eastern 4 n k F-1 Irrigation I rH P � State Work Done 1 Repair Work D ❑ Type of Pump I (top 50'1 :Sealing.Materia Well uction ❑ We11-Qiameter _ E..-_M. Depth Filler aterial {Below 50') rmitted if public sewer is i _ __ available within 200 feet. ( TYPE OF SEPTIC:WORK: 'NEW INSTALLATI0IV ❑r REP.AIRI.ADDIT-ION ❑ DESTRUCTION ava(Noilable septic system pe l j knstallation will serve: Residence, Commercial Other i t S i Number of living units: ! Number of bedrooms Water table depth Character of soil to a depth of 3 feet:. Capacity-- No. Compartments SEPTIC TANK ❑ Type/Mfg -Mi'thod of Disposal PKG.TREATMENT PLT"❑ no °Pro a Line Distance to nearest: Welly Foundation p r i Total length/size LEACHING LINE ❑ No. & Length of lines ---------- t I Pro a Line L Foundation P rty , FILTER BED ❑: Distance to nearest: Well ,., w ' Size Number k SEEPAGE PITS j,,, r❑f Depth 1a Property Line 'Distance to nearest: Well SUMPS Foundation i DISPOSAL PONDS ❑ I hereby 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 District. work for r shall not Home owner or licensed in such h manna gas to become subjecnature certifies the tlto workman's_compensat on lng: "I certify that in the aewsoof California."aha Contractor's which ng or perthis -contractingcont act ngt is issued, l signature pensa employ any perso — persons subject to workman's compensa certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ tion laws of California."„ The applicant m f call for all required inspections. Complete drawing on reverse side. J Date: " Title: _ ` a Signed i �. � FOR DEPARTMENT 135E ONLY Sri3 Date Area Application Accepted by } � Date } Date Final Inspection by Pit or Grout Inspection bq i Additional Comments: k - ❑ Tacy ` ❑ Stk 466-6781..:; ❑.Lodi 369-3621. ❑ Manteca- 823-71 Box 2009..Stk., CA-95241 Applicant - Return all copiesxo: Environmental Healt PermitbServices 1601.E. Hazelltoon4Ave.,P.G., CK RECEIVED BY DATE PERMIT NO. FEE AMOUNT DUE AMOUNT REMITTED C H INFO EH 13-24 MEv. ` EH 14-28