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A APPLICATION,FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT ' 1601 E. HAZE:.TON AVE.,.STOCKTON, CA 6\— i Telephone 12491 466-6781 kV i i PERMIT EXPIRES 1 YEAR FROM DATE ISSUED �, f ete in Triplicate ' k (Complete ) � kation is f No:549 for sewage or No. 1862 for welll.pump and the Rules and Regulations of the San Joaquin Application is hereby made to the San Joaquin Localncealth District for a permit to construct and/or install the work herein described.This app He ` a compliance with San Joaquin County ordinance . kk' made in comR' f Local Health District. " ' PM r C.ct.c.�i Lot Size City I Job Address Phone Address , Owner's.Names' .. License No.----Phone I Address DESTRUCTION ❑ Contractor WELL REPLACEMENT ❑ TYPE OF WELL/PU ',NEW WELL ❑ OTHER ❑ i SYSTEM REPAIR ❑ P P P INSTALLATION ❑ DISPOSAL FLD. NK SEWER LINES �„:.�--.-- p1T51SUMPS DISTANCE TD,NEAREST: SEPT AGRICULTURE ICULTURE WELL UCTION SPECIFICATIONS INTENDED USE TYPE OF WELL PROBLE Dia. of Well Casing ❑ Open Bottom ❑ M r Well Excavation \ Specifications ❑ Industrial Type of Casl ❑ Tracy Type of Grout ` + Domestics Private ❑ Gravel Pack ❑ Delta Depth of Grout Seal 4 Q� ❑ Public ❑ Oth �3 Seal I �Approx. Depth ; ❑ Eastern Surface Seanstalled by Q ❑ Irrigation H P State Work Do Repair Work Doe ❑ Type of Pump Sealing Material (top 50') W estruction El Well Diameter �� ► �1 Filler Material {Below 50 Depth '1 " ,.,, 4-� ailable within 200 feet.f TYPE OF SEPTIC WORK: NEW INST ._ ALLATION ❑a REPAIR/ADDITION F1 DESTRUCTION (No septic system permitted if ptsb is sewer is /f Installation will serve: Residence Commercial, Other�� ► 1( Number of living units: Number of bedrooms Water table depth Character of soil to a epth of 3 feet: "�Capacity No. Compartments SEPTIC TANK Type/Mfg v, Method of Disposal TREATMENT ATMENT PLT.❑ i Foundation .Property Line Distance to nearest: Weil Total length/size LEACHING LINE ❑ No. & Length of lines Foundation -Property Line FILTER BED Ll Distance to nearest: Well Size Number SEEPAGE PITS.. O Depth SUMPS C1 Distance to nearest: Well Foundation Property tine DISPOSAL PONDS ❑ 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, an rules and regulations of the San Joaquin Local Health District. the following: "I certify that in the.performance of the work for which this permit is issued, I shall not Home owner or licensed agent's signature certifies employ any person in such manner as to become subject to workman's compensation laws of California." ploy ersonslsuti subject t workman'scompensa- certifies the following: "I certify that in the performance of the work for which this permit is issued,I shah employ pe tion laws of California." r The applicant mupF call for all required inspections. Complete drawing on reverse sid / ^ �7 Titley Date: Signed X J� FOR DEPARTMENT USE ONLY Date �—' Area Application Accepted by i Date Pit or Grout Inspection by �1 Final Inspection by at� Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 623 7104 ❑ Tracy 835 638,` Applicant Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009; Stk.s CA 95201 FEE AMOUNT DUE AMOUNT REIUIITTED CK RECEIVED 9Y DATE PERMIYNO. LINEH 13.241REV.1/8tI EH 14-28