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i F APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466 6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED { {Complete in Triplicate) fff' Application is hereby maith a to the San i Caupty O dinauin lnce No. 549 for sewage or Health District for a permit Na 1862 for we 1/dpumlp and the Rules and nstall the work herein gulations of the San Joaquin made in compliance Local Health District. r City Lot Size -3 he re.-5 PM '10- { -016 Job Address .4 44,6EY' j Phone 15 Owner's Name Address -�- 3 License No.G _2 S 7P1one G Contractor �a� W)A, Address TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLA EMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER K ml m I �l/ f DISPOSAL FLD.A PROP. LINE �s DISTANCE TO NEAREST: SEPTIC TANK / SEWER LINES _10L_ IVIA FOUNDATION _�.-- AGRICULTURE WELL OTHER WELL pOC� PITS/SUMPS - ,. :_ TENDED USE TYPE OF-VIIELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Weil Casing I Type of Casing_. /A Specifications ❑ Domestic!Private ❑ Gravel Pack ❑ Tracy � Type of Grout C e�? at. t; l'1 Public Other D Delta Depth of Grout Seal I I Irrigation 7.0-Approx. Depth i I Eastern Surface Seal Installed by_ �y J/A H P State Work Done Repair Work Done L7 Type of Pump -�"� -- b e 1 k Well Destruction ElWell Diameter Sealing Material Itop 50'1 c e yy)? Depth Filler Material ISelow 50'1 N I- TRUCTION l 1 TYPE OF SEPTIC WORK: NEW INSTALLATION {:I REPAIWADDITION l 1 DESavailablewithin200 feetit'ed if public sewer is l n Installation will serve: Residence .t Commercial— Other m V 1 Number of living units: Number of bedrooms74 Water table depth Character of Soil to a depth of 3 feet: Capacity No. Compartments SEPTIC TANK ❑ TYPe/ IgMethod of Disposal Lla1 PKG. TREATMENT PLT. Distance to nearest: Well Foundation Property Line s Total length/size LEACHING LINE ❑ No. & Length of lines FILTER BED ElDistance to nearest: Well Foundation Property Line f I SEEPAGE PITS l I Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ will be done in accordance with San Joaquin county ordinances, state laws, and I hereby certify that I have prepared this application and that the work 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 shall not signature employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's nslsub sring ubject to wo�kmanirscompensa certifies the following:"I certify that in the performance of the work for which this permit is issued,!shall employ pe I tion laws of California." j The applicant must call for all required ins ctions. Complete drawing on reverse si Signed X ' Title: Date: a FORD TME ONLY Date Area Application Accepted by G Pit o Grou Inspection by ' Data Q Final Inspection by Date y 0 Additional Comments: /;, S V vl�T7� �t iiJCGJ`Jt ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835 6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 f # FEE AMOUNT D1UE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. se INFO g 1 `'j ' a,EH 13-24(REV. H 51 4 13 (AI -!�`- EH 14-26