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+ L APPLICATION FORFPERMIT SAN JOAQUINILOCAL HEALTI•I DISTRICT ID1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-67$1 ,;,. "r, : PERMIT EXPIRES,1 YEAR..FROM DATE ISSUED :(Complete in Triplicate),; 3X . l•:`.;� . +■�= `v application is Application is hereby N a e to the San Joaquin n County ordinance Local No.'District far sewage r r'No. 1862 fart to ewell Jfp'ump and the Rules and'Regulations of he San Joaquin made in compliance Local Health District.Y n^ r 4., Lfr� 14�°.t; ..� =L1:C f��sE* , vfr G Lot Size 9 PM City Job Address Address= 3p�/- _" �" Phone Owner's Name �rn_ - t »� Phonewe Conti'actop'{IVame?t &License No., y� TYPE OF WELL/PUMP:� I N WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ l SYSTEM REPAIR ❑ OTHER ❑ < PUMP INSTALLATION ❑ SEWER LINES —�-- DISPOSAL FLD. PROP. LINE . t DISTANCE TO NEAREST: SEPTIC TANK PITSISUMPS FOUNDATION AGRICULTURE WELL OTHER WELL i INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS pia of Well Casing C:1 Industrial F-1 Open:Bottom ❑ Manteca Dia. of Well Excavation Specifications ❑ Tracy Type of Casing R ❑ Domestic/Private ❑ Gravel Pack Depth of Grout Seal Type of Grout ❑ Public ❑ Other „ ❑ Delta ---Approx. Depth ❑ Eastern Surface Seal Installed by ❑ Irrigation ._ State Work Done Repair Work Done ❑ Type of Pump ;Sealing Material{top 50'1 f~I Well Destruction D Well Diameter Filler Material (below 501 V r Depth TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION X DESTflUCTION ❑ aNaila Islvvihin 200 feet.)ed if public sewer is .. Installation will serve: Residence� Commercial.� , Other Number of living units: Number of bedrooms o ri Water table depth _ Wi� Character of soil to a depth of 3 feet: ' � _ Z Type/Mfg Ac, `�� 1 Capacity f Q No. Compartments SEPTIC TANK Yp `"§ i' Method of Disposal PKG. TREATMENT PLT. ❑ Well hSiFoundation__1_g Property y Line Distance to nearest 3 1 I } . LEACHING LINE No. & Length of lines SS ; Total length/size. ength/size 6� l Property Line { 1FILTER BEDS r ❑ Distan ce.to nearest: Well 1S ` "Foundation 1 ' l 1 Number TS' ❑ 'Depth SEEPAGE PISize' Foundation Property Line ' SUMPS "❑ Distan�eto' nearest:- 'Well :j DISPOSAL PONDS "El e isiapplicaiio> ahil that'th"e vro7k";will"be'done`in accordance-with"San,Joaqu`n.countyordinances, I hereby certify that l have prepared thstate laws, and l not rules and regulations of the San Joaquin_Local-Heaith Distric{. " .f v `-_ ` wdrk for Home owner o licensed in-such manner as to.become subject to r ving-o k an'srtcompensation lify that in the aewsoaf Californiarmance of h8 Contractor which ngl or sub-contractinglsignlature 'employ any pe certifies the following:"I certify that in the performance-of'tfie work for which this permit is issued,I shall employ persons subject to workman's campensa- tion laws of California." I <++�` -1 µ i I The applicant must c for all required inspections. Complete:drawing on reverse side. `,'8.�..�Tit1e: � Date: d "Signed FOR DEPARTMENT USE ONLY j I Area Application Accepted by.. - l ! Date ..;. .. ,{ r" pate !�!� Pit or Grout Inspection-by ,�- Date E� Final Inspection by Additional Comments. ` Stk 466-6781 ❑ Lodi- 369-3621 Manteca 823-7104 ❑ Tracy P.O. Box 2009, 5tk., CA 95201 85" C1 [3 " Applicant Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave.+re. .._CK RECEIVED BY DATE PERMIT N . - FEE° AMOUNT DUE AMOUNT'REMITTED' CASH INFO, _ + EH 13-24 IREv.10!831 1 - .- EH"1428