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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE;_T ON AVE., STOCKTON, CA Telephone (209) 466-6751 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) 549 for sewage yr No. 1962 for wyell/pump and the Rules and Regulations of the San Joaquin made in c Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described•This application is made in compliance with San Joaquin County Ordinance o Local Health District. F45- G PM 1111111111: �j �� City '� Lot Size Job Address J� Phone one Agdre/s Qwner's Name .,�I�c d`d SS _d ��'�,C�J��Litense No. f Phone t u Contractor DESTRUCTION ❑ NEW WELL ❑ WELL REPLACEMENT ❑ t TYPE OF WELL/PUMP: SYSTEM REPAIR ❑ OTHER 13 PUMP INSTALLATION RF.eA,,�I�Lj4 DISPOSAL FLD. PROP. LINE r' SEWER INS J PITS/SUMPS DISTANCE TO NEAREST: SEPTIC TANK —�� AGRICULTURE WELL OTHER WELL FOUNDATION �� TYPE OF WELL PR08L� CONSTRUCTION SPECIFVCATIONS Dia. of Well Casing INTENDED USE C] Open Bottom ❑ Manteca Dia. of Well Excavation Specifications I Mlndustrial Type of Casing ❑ Gravel Pack ❑ Tracy Type of Grout ❑ Domestic/Private ❑ Delta Depth of Grout Seal ❑ Public ❑ Other ' �gpprox. Depth O Eastern Surface Seal Installed by �lBf Is D E � ❑ irrigation H P State Work fDone Repair Work Done ❑.b�Type of Pump - (tOP-; --� ❑ �' Well Diameter Sealing Material (top 50 I Well Destruction�` Filler Material (Below 50'1 r r Depth ermitted if public sewer is available within 200 feet./ TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ .DESTRUCTION ❑ ava septic system Installation will serve:,,,,fResidence— Commercial— Otherk Number of living units: Number of bedrooms Water table depth Character of soil to a depth of 3 faet: l Capacity— No. Compartments i IiFSEPTItC TANK ❑ Type/Mfg Method of Disposal PKG.,TREATMENT PLT.❑ 1Foundation Property Line—� I.A ` - -Distance to nearest: ' `"Well- V Total length/size LEACHING LINE D No. &rLength of lines Foundation Property Line FILTER BED Ll Distance to nearest: Well j ' Size Number SEEPAGE PITS E3 Depth: Property tine SUMPS L:1 Distance to nearest: well Foundation i DISPOSAL PONDS ❑ I 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.g that in the performance of the work for which this permit is issued, I shall not I Home owner or licensed agent's signature certifies the followin I `compensation laws of California."Contractor's hiring or sub-contracting signature employ any person in such manner as to become subject to workman's comps certifies the following:"I certify that�the perfomtia n ce of the work for which this permit is issued,I shall employ persons subject to workman s compen - tion laws of California." The applican us all r all re inspection .'Complete drawing on revs .Sde Date. k Title: Signed_ l FO DEPA=Final Y �� Date Area v G y Application Accepted by Date �'7ill� T Pit or Grout Inspection by Date on by Additional Comments: ❑ Stk.�4666781....••--•-D-Lodi-369-3621,..,.—Y❑ Manteca—ffi3-7104..---El-Tracy�-835-M Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 Applicant- Return all copies to: E FEE AMOUNT REMITTED CK RECEIVED BY DATE r � N PERMIT'NO. vr AMOUNT DUE CASH INFO + EH 13-24(REV.1/a 51 EH 14-26 _ _