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APPLICATION FOR PERMIT ol t' SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA NO�1 -� Telephone (209) 466-6781 n A PERMIT EXPIRES 1 YEAR FROM DATE ISSUED . (Complete in Triplicate) scribe �A�' application.This is Ale-, i Application is hereby made to the San JoaquinO Local na He lth 5 District for sewage or it to 1862 construct or and/or install and the Rules and in de ations of the San Joaquin gu made in compliance with San Joaquin County Local Health District, Lot Size PM City Job Address Lo Phone Address owner's Name I i License Phone E Address Contractok WELL REPLACEMENT 11 DESTRUCTION LI TYPE OF WELL/PUMP: NEW WELL 11SYSTEM ❑ SYSTEM REPAIR ❑ i PUMP INSTALLATION ❑ SAL FLD. PROP, LINE DISTANCE TO NEAREST: SEPTIC TANK I SEWER LINES PITS/SUMPS AGRICULT L OTHER WELL FOUNDATION AREA`"CONSTRUCTION SPECIFICATIONS'-'" ' ` INTENDED USE TYPE OF WELL ' '.PR Dia. of Well Casing f El open Bottom Manteca Dia. of Well Excavation k ❑ Industrial Specifications — ❑ Tracy Type of Casing ❑ Domestic/Private ❑ Gra ck Type of Grout ---- ;,-Depth l Public Other n Delta Depth of Grout Seal _-Approx. Depth I 1 Eastern Surface Seal Installed by � I I Irrigation H P : ' �� State Work Done__ ' Repair Done ❑ Typ of Pump x Well Diameter �_—� Sealing Material (top 50'1 1 W estruction ❑ ; * Depth i Filler Material I_Below 50') € - "r—F.. 1 available within 200 feet.) f TYPE OF SEPTIC WORK: NEW INSTALLATION I ! REPAIR/ADDITION l 1 DES`RUCTION ava(Noilable septic system permitted it public sewer is Installation will serve: Residence Commercial_ Other I' Number°f living units: Number of bedrooms Water table,depth Character_of.soil to a depth of 3 feet: Capacity No. Compartments ( SEPTIC�T K ❑ Type/Mfg Method of Disposal PKC. TREATMENT PLT. ❑ _ tfoundation Property Line Distance to nearest: Well tr..r Totallengthlsize LEACHING LINE ❑ No. & Length of lines Line FILTER FILTER BER o ❑ Distance to nearest: Well Foundation` " Property 1Size - _Number SEEPAGE PITS 4 I Depth SUMPS LlDistance to nearest: Well Foundation Property Line i DISPOSAL PONDS ❑ I rk will be done in accordance with San Joaquin county ordinances, state laws, an I hereby certify that l have prepared this application and that the wo rules and regulations of the San Joaquin Local Health District. y that in the g' work for Home owner or licensed agent's manner torbecome subject folio wing: "I emit compensation laewsoof California."Contract dsrhui gr o¢sub cont acting signermit is issued, I latu�e s employ any person in s ing: "I certify that in the performance of the work for which this permit is issued,t shall employ persons subject to work certifies the follow marl compens - tion laws of California." , The appl617 icant t call for al! required inspections. Complete drawing on rev side. f / f� s'f7�� Date: (a [ Title: _ �� .., �- Signed F DEP�'Mr-NT USE ONLY 1 S^�-7 Q� 1 date Area Application Accepted by mo` _ Final Inspection by Data Date Pit or Grout Inspection by Additional Comments: ❑ Stk 466 6761 ❑ Lodi 369-3621 ❑ Mant 823-7104 ❑ Tracy 835-M Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 K RECEIVED BY DATE PERMIT-NO. FEE AMOUNT DUE AMOUNT REMITTED CASH - INFO r + EH 13-24 MEV.1/H 5) � �� !tJl7 EH 14-26 --