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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., :STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUEDt _ r (Complete in Triplicate) This-a is install the work descri , pp cation Application is herebyma a to the San County orcal lnce No.HealD 549 for sewage or permiNo 1862 forcwell/dpump and the Rules and'Regulations of he San'Joaquin made in compliance with Local Health District. y— (�/ Q I rt - CiW It",- ey Lot Size PM Job Address Phone -- - �'J Owner's Name — Address C � � 3 '-�lUf Contractor's Name'' u c a . License No" Phone 1 TYPE OF WELL/PUMP_ NEW WELL Ll SYSTEM REPLACEMENT [3 DESTRUCTION C PUMP INSTALLATION G SYSTEM REPAIR ID ❑ I _ SEWER LINES _ DISPOSAL FLD. PROP. LINE: } DISTANCE TO NEAREST: SEPTIC TANK AGRICULTURE WELL — OTHER WELL PITS/SUMPS FOUNDATION; INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS — Dia. of Well Casing _ 1 "❑ Industrial D Open Bottom ❑ Manteca Dia. of Well Excavation Specifications 1 Type of Casing c El Domestic/Private ❑ Gravel Pack ❑ Tracy OhDepth of Grout Seal _ Type of Grout' ' D ter t-1Delta O [3Public El Irrigation fAPprox. Depth El Eastern Surface Seal Installed by— 1 H P _— ` State Work Done Repair Work Done E-) Typeof Pump` �. Well Destruction f] Well Diameter Sealing Material (top 501 a 4 Depth Filler Material (Below 501 — . TYPE-OF-SEPTIC-WORK: 'NEW INSTALL-ATION C�!REPAIR/ADDITION-O--DESTRLICON ❑ a�aiI bpe wth ne200 feettted if.public sewer is ,} f Installation will serve: Re$idence Commercial__ Other + Number of living units: Number o bedr oms , epth -----Water table d _ Character of soil to a depth of 3.feeta 'TOO No. Compartments d L Type/Mfg Lm= Capacity��— SEPTIC TANK fd f � Method of Di4posal PKG. TREATMENT PLT. D ' Foundation—�Q-- Property Line 5 i Distance to nearest: Well Foundation � — __ Total length/sized � w LEACHING LINE No. & Length of lines _ 4'© Faurtdatron — r r ICS Property Line FILTER BED �i Distance to nearest: Well - - Number aSize ,.-,,'SEEPAGE PITS Ci Depth c :.rf�. _, - .. . — Fundation Property Line- } SUMPS EJo Distance to nearest: Well -- '- ` D SPOSAL PONDS ❑ ' . 1 hereby certify that I have prepared this applidation and that the work will be•done in accordance with San Joaquin'cou` ordinances, state laws, and rules and regulations of the San Joaquin Local-Health-District. 9; - nature r compensation laws of California." Contractors hiring or sub contracting sig Home owner or licensed agents signature certifies the followin 1 certify that in the performance of the work for which this permit is issued, I shall no employ any person in such manner as to become subject to workman's comps to rsons subject to workman's compensa- t that in the performance of the work for which this permis issued,I shall employ Pe r certifies the following: "I certify i tion laws of California." '+ ,a'� f., � ° ' Thewplican ust call r all requiredlinspection�Complete dcw,ng on reverse'sid, Date: nL9, Title: P Signed X- 1, + FOR OEPENT USE ONLY Area —' _ Date Application Accepted by t Date Date Final Inspection by i Pit or Grout Inspection by k (� G 6Gc( { Additional Comments: 104 El 83`x6385 ` �jyr�u.� ❑ Stk 466-6781 U Lodi 3& 3621 0,Manteca Stk., CA 9821 Applicant- Return all copies to: Environmental Hesfth Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, CK - PERMIT'NO FEE AMOUNT DUE . AMOUNT REMITTED CASH RECEIVED BY DATE ' INFOl'3l �\ 3 r /moi ss mss + EH 13-24(REV"10183) 11✓t c. w-.r�