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Jl( APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT r 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6761 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ut , (Complete in Triplicate) This all the work made iApplican is hereby arca ma a to the San JoaquinJoaquin County Ordinance Health No,.Dist for sewagcation is e or+No.1862 fort to cwell/dpump atnd the Rules and+R gulations of he Sanl Joaquin ith Local Health District... ., / ��tt a Lot Size. PM Job Address (I SU l �f — — ✓IOSQ� /[INNcKC� Phone y— �. .. - Address Owner's Name - ' Phone '. 9 7 0.(Q .. i Ucettse No. Contractor's Nam WELL REPLACEMENT ❑ DESTRUCTION ElTYPE OF WELL/PUMP: NEW WELL ❑ OTHER Cl { -- PUMP INSTALLATION C3 DISPOSAL REPAIR ❑ IDISPOSAL FLD. PROP. LINE-__ t DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES AGRICULTURE WELL OTHER WELL PITS/SUMPS f FOUNDATION, I INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing ❑ Industrial ❑ Open Bottom ❑ Manteca Die. of Well Excavation Specifications + ❑ Gravel Pack, ❑ Tracy Type of Casing t ❑ Domestic/Private I Depth of Grout Seal Type of Grout j 'El Public ❑ Other ❑ Delta t �pprox. +epth ❑ Eastern Surface Seal Installed by ❑ Irrigation H.P. State Work Done t 'Repair Work Done El Type of Pump Well Destruction ❑ Well Diameter Sealing Material(top 501 •f Depth ; Filler Material iBelow 50') rmi TY?E-OF-SEPTIC-WORK:--NEW INSTALLATION REPAIR/ADDITION-O^DESSRU ON O-avail th na200 feettted-if.public sewer is U , .. ) ll Installation will serve: Residence v', Commercial— Other / Number o bedr oms -� / (b V'•r Number of living units:_ Water table depth Character of soil to a deptof 3 feet:; / �Paci�,, I a No. Compartments ` SEPTIC TANK L7 Type/Mfg - . . ,•. ' �r ,fl� r r} Method of Di�posa PKG.TREATMENT PLT. C3i' I Property Line r . f Dista to nearest: Well Foundation i (3�.---•�-�- -^�"' Total length/size 'r p�No. &Length of lines , + - LEACHING LINE =+Foundation=l Ur Property Line 5 FILTER BED Cl Distance to nearest:-" Well _ n,.- dam.• � Number " ✓1 SEEPAGE PITS ❑ Depth f .-.�•,,,. __,S Property Una . ' s SUMPS ❑ Distance tonearest: Well 'Foundation rµ DISPOSAL PAS L ONDS ❑ -- I I hereby certify that I have prepared this application,and that the work wiTbe,done in accordance with San Joaqu n'county ordinances, state laws. an ` i miss and regulations_of the Ssn Joaquin Local•Health-District.g. / Home owner or licensed agent's sgnsture_certiflas th6J.011owin 'I certify that in the performance rn the work for which this permit issued, I she not employ any person in such manner as to become subject to workman;s compensation laws of California:' Contractors hiring or sub-contractingworkman's c signature i rformence of the workfor which this pe1m�s issued,I shall employ persons_subject to workmen's compensa- i Certifies the following: ,I certify that in the pe tion laws of California." ,} +"V4 P: 1 The•spplicen�.(�ust cell r allllrequired inspections. Complete drawing on reverse side. � ., Date: I \1 ��Jt-t'f¢iL.ej,�` Signed X t ♦�' ;"' POR DEPAFITMENT USE ONLY Date�— Area Application Accepted by — t L Date f Date Final Inspection by '+ Pit or Grout Inspection by •� ��y&009, � / � Q.Additional Comments: ❑ Lodi 369-3fi21 ❑,Manteca 19237104 LI Iracy 835-6385Stk 466-6781 P.O. k., CA 98201 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. He Ave., CK - DATE PERMIT`NO. FEE AMOUNT REMITTED , CASH RECEIVED-BY, : - INFO /'MOUNT DUE 7 + EH 1}2♦IREV.