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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT „ 1601 E. HAZEL T ON AVE., STOCKTON, CA , Telephone (209) 466-6781 1000RAIT EXPIRES j,YEAR FROM DATE ISSUED (Complete in Triplicate) ` auin Local Health District for a pe Appliction is hereby made to the San Joaqrmit mto construct and/or install the work herein described. This application is made a compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pup and the Rules and Regulations of the San Joaquin Local Health District. /„ / City Lot Size PM Job Address (1p A_ ddress�� Phone j r rAddress _ License No.��", Phone Contr ctor DESTR<)CTI. Q 1:: Y WELL REPL4CEMENT`i7 r�1 TYPE'OF WELL/Pump:.`%wo NiEW V11ELL`-1 4 ` OTHER'❑ PUMP INSTALLATION ❑ a 5YS7EM REPAIR ❑ �J �1 '�' - \'`� I 4' + >' `i �' SEWER LNES -� _'' F DISPOSAL FLD_ . PROP. LINE JDISTAANCE TO NE' T:'`,SEPTIC TANK , j �ti0 H R;WELL` '"�� PITS/SbMPS �AGRICULib`ht,WELL s '�, `f?ROBLEM AREA CONSRUCTION'SPECIFICAT_:IONS•.. INTENDED_ %USES,�N ,�TYPE fl SWELL _ _ - Dia, of Well Casing ❑ industrial ' ❑ Open Bottom K ❑.Manteca . Dia. of Well Ixcavatiori' ��'\!ice h =, :en °+5� � '�1 �, I Specifications Type of Casing Domestic/Private " ❑`Gravel Pack ❑,Tracy Depth of Grout Seal Type of Grout - r 71 Other k � �C1'Deltal 1-1 Public . I "' :" Surface Seal Installed by li I Irri'ation -tApprox_ Depth I I Eastern r Well Destruction 'SmH P State Work Done ?Repairs Work Done ❑ Type�of Pump ; i k ��i� W�t1�Diameter�_ Sealing Material (top 50'I c 1pe p th. I� Filler Material {Below 50'1 I - JNo TYPE OF SEPTIC WORKi's NEW INSTvALLAT_ION REPAIR�ADDITION t 1 DESTRUCTION l } aailabPe1w'thin 200 feet.) if public sewer is ' installation will serve: Residence 'k� Commercial Qther Number of living units: Number of bed ro m N Water table depthQ i Character of soil to a depth of 3 feet: Compartments SEPTIC TANK ❑ Type/Mfg Capacity � { Method of Disprfs i [ 1PKG.TREATMEN I PLT- Cl Distance to nearest: Well ®� Foundation /01 Property Line Poll Ile f ZD _ Tytal*1ength/size LEACHING LINE Na. & Length of lines L L� t ✓ Foundatia Pro¢ffftj7=Eirse •��---- FIL_TER BED 0 Distancb t4 nearest: Well� = -- !oNumberT===-== C�° r 4 I S 1 1�Depth Size --. . - - t . `` .� Foundation J _��— Property Lie ,ti [-1'•-Distance to nearest: Well Y. D+6P4,6+44--PONDS ❑ hereby certify that I have prepares application and that the work will be done in accordance withSaJoaqumcounty ordinances, state laws, an rullnot es and regulations of the San,Joaguin Local Health-bisfrict. 'i Home owner-or licen ed,agent s srgas to become subject lto wok man'srtcoythat in mpensation lhe aws�o Caiiforn arfnanc h11 dontract,4hiringl or sub-contracting)signature toemploy any persollin such mannererson subject to workman's compensa- F Certifies the following: '9 Certify that in the performance of the work for which this permit is issued, I shall employ p l tion laves of�California." 1. The appli t must call for all-required inspections. Complete drawing on reverse side. ' N� ! T Title: Date: Signed e l FO EPARTMENT.USE-ONLY :a ems• r Area r� Application Accepted-by-�--• G' i Final Inspection b date r Pit or Grout Inspection by Wet f}� ` Additional Comments: El Stk 466 6781 ❑ Lodi 21__ ._.❑Mantepa=823-7104 �-.,_❑Trpcy 835,6385-. .- �_- ----- .7r .- -e.-- - Applicant - Return all copies to:Environmental Health Permit/Services 1 E..Hazelto Ave., O. Bax 2(109, 5tk., CA 95201 FEE CK RECEIVED BY Zia.:s AMOUNT DUE AMOUNT REMITTED YNFO y_ 1 r EH 13-24 IttEY. ��9 EH 14-28