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APPLICATION FOR PERMIT PAYMENT SAN JOAQUIN LOCAL HEALTH DISTRICT R E G1E I V S D 1601 E. HAZELTON AVE., STOCKTON, CA �9 � Telephone {209) 466.6781 OCT PERMIT EXPIRES 1 YEAR FROM DATE ISSUED NVIRONMENTAL HEALTH �.. ,. (Complete in Triplicate) �Sn is T far sewage or No. 1862 for wail/ pump and the Rules and Regulations of the San Joaquin Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein dea#1�1 1 made in compliance with San Joaquin County Ordinance t ,r Local Health District. PM Lot City Lot Size Job Address 5-z7 �o ?5 Q Q Phone �.. � Address Owner's Name // ' ��y,� — L04 rinse No.� Phone Contractor _` r� Address 16 DESTRUCTION ❑ NEW WELL � WELL REPLACEMENT ❑ OTHER ❑ TYPE OF WELL/PUMP: SYSTEM REPAIR ❑ PUMP INSTALLATION ❑ DISPOSAL FLD.��d f PROP. LINE } � SEWER LINES �- PITS/SUMPS DISTANCE TO NEAREST: SEPTIC TANK Jr 4 AGRICULTURE WELL. OTHER WELL FOUNDATION- INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATION Dia. of Well Casing ❑ Open Bottom Manteca Dia. of Well Excavation Specifications L] Industrial Tracy Type of Casing 00 Gravel Pack ]/ Type of Gro Domestic/Private 0 Other ❑ Delta Depth of Grout Seal ❑ Public Surface Seal Installed by 1:1 Irrigation _--Approx. Depth ❑ Eastern H.P. State Work Done �-- Repair Work Done Ll Type of Pump. Sealing Material (top 50'1 _ Well Destruction F] Well Diameter —� Filler Material [Below 501 Depth available within 200 feet T. EI OF NEW INS SEPTIC WORK: ALLATION ❑ REPAIRlADD. ION ❑ DESTRUC TTION L3 (No septic system permitted if public sewer is serve. ResidenceResidence�. Commercial Other G Installs i Number of living units: bar of bedrooms Water table depth Character of soil to a depth of 3 feet: Capacity��-- No. Compartments r SEPTIC TANK ❑ Type/Mfg Method of Disposal PKG. TREATMENT PLT. ❑ Foundation Property Line Distance to nearest: Well i i Total tengthlsize LEACHING LINE ❑ No. & Length of•lines Foundation— Property Line FILTER BED ❑ Distance to nearest: Well Size Number I SEEPAGE PITS ❑ Depth Property Line E Foundation —� SUMPS ❑ Distance to nearest: Well � •� DISPOSAL PONDS Elerti that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and I hereby c f1r rules and regulations of the San Joaquin Local Health District.g that in the performance of the work for which this permit is issued, I she not Home owner or licensed agent's signature certifies the ft to I certify of I shall employpersons subiect to workman's compensa- employ any person in such manner as the becomerfomancecof the work for which this tpe mR�is issued, Contractor's hiring or sub-contracting signature certifies the following."I certify that in. pe tion laws of C ifornia." ever side. } The app cant ust call Ivor al req ed inspection . Complete drawing Date: Titi Signed wr _ FOP DEP TENT US ME ON date /d 7 Area Appiicatio ccepted by ` G Date�— Pit orkrou/tLpection by Date - —a 7 Final inspection by i # Additional Comments: ❑ Manteca 8Z3 04 ❑ Tracy t LlStk 466-6781 C3 Lodi 369-3621 5201 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009• Stk., CA 9 RECEIVED BY DATE PERMIT`NO. FEE AMOUNT DUE AMOUNT REMITTED CASH ' INFO + EH 1324(REV.1/a 5] EH 14-26