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APPLICATION FOR PERMIT SAN JOAOUIN LOCAL HEALTH DISTRICT 1601 E: HAZELTON AVE., STOCKTON, CA Telephone (209) 466-.6781 PERMIT EXPIRES 1 YEAR FROMDATE ISSUED (Complete in Triplicate) r for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin hereby made to the San Joaquin Local Health District fora 9 ermit to construct and/or install the work herein described. This application is Application is he Y made in compliance with San Joaquin County Ordinance No.54 Local Health District. �V fcity, PM Lot Size Job Address J Phone 17 a G � L Owner's Name Address pp Phone A f License AddresspESTRUCTIO + ontracWELLIPU tor WELL REPLACE MENT ❑,. NEW WELL n OTHER ❑ TYPE OF i SYSTEM REPAIR a'LINES PROP, LUNE SEWER PUMP INSTALLATION ❑ POSAL FLD. DISTANCE TO NEAREST: SEPTIC TANK ---- AGRICULTURE W OTHER WELL�- PITS/SUMPS FOUNDATION —�� TYPE OF WELL PROBLEM AR CONSTRUCTION SPECIFICATIONS Dia of Well Casing INTENDED USE ❑ M ca Dia. of Well Excavation �.� ❑ Industrial ❑ Open Bottom �Specificat�ns 'R ❑ Gravel Pack Tracy Type of Casing ❑ Domestic/private Depth of Grout Seal Type of Grout �------ C1 Other Fl Delta a' * PublicSurface Seal Installed by >- 1 1 Irrigation pprox. depth l 1 Eastern State Work Done— f P Type of _�— H.P. R Repair Work Done Sealing Material flop 501 �1 Well Destr n ❑ Well Diameter Filler Material (Below 50') ^t Depth , v r- _�,,,� -: .••• -H--- -. vailable within 200 feet'. TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIRIADDITION l I DESTRUCTION (No septic system permitted i! public sewer is ICommercial— Other I installation will serve: Residence r 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 Method of Disposal ` f � t �\ PKG. TREATMENT PLT. ❑ Foundation—.Property Line Distance to nearest: Well Total length/size c LEACHING LINE ❑ No. & Length of lines Property Line . FILTER BED ❑ Distance to nearest: Welt Foundation Number [ h Size I Dept SEEPAGE PITS Foundation Property Line Ll Distance to nearest: Well SUMPS ry y -- 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: `� - �. Home owner or licensed agent's signature certifies the following:-I certify that in the performance of the work for which this permit is issued, I signature shallnot s of California." Contractor's ring or sub-contra employ any person in such manner hat s to n the perfoemance of�he work for whichthis permation tVis issued, I shall employ persons ksubject to workmanlsgcompensa- certifies the following: "I certify tion laws of California." { The appli mus call for all requi inspections. Complete drawing on reverse side. . int Date: Title: U ��''�"-' Signed X I FOR DEPARTMENT USE ONLY / I Date Area r ` Application Accepted by Date Date Final 1 spection by I Pit or Grout Inspection by t � f Additional Comments: 369 3621 ❑ Manteca LD Tracy 835-6385 ❑ Stk 466-6781 ❑ Lodi al Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 Applicant - Return all copies to: Environment CK RECEIVED BY DATE PERMIT ND. FEE AMOUNT DUE AMOUNT REMITTED CASH C� z I INFO /// ��j] Cd U / `'✓ � � +.EH 13-24 IREV.t -- EH 14.26