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~ APPLICATION FOR PERMIT SAN JOAnUIN'LOCAL HEALTH DISTRICT 1601 E. HAZE-Ii ON AVE., STOCKTON, CA r: Telephone (209) 466-6781 ' PERMIT EXPIRES TYEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct einstall the work herein described.This application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for wll1pulllpump and the Rules and Regulations of the San Joaquin Local Health District. � City Lot Size PM , Job Address Address �`LL'.— --------------- Phone Owner's Name i M � Phone Address ��`� License No.��.-- Contractor NT ❑ DESTRUCTION ❑ ELL REPLACE ME ` NEW WELL ❑ W \ TYPE OF WELL/PUMP"", 1SYSTEM REPAIR ❑ OTHER fl PUMP 1NSTALtAT10N�RE/ f1C PROP. LINE DISPOSAL FLD. PITS/SUMPS t SEWER LINES DISTANCE TO NEAREST: SEPTIC TANK FOUNDATION AGRICULTURE WELL _ OTHER WELL \� INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia of Well Casing V El Industrial El,Open Bottom ❑ Manteca Dia. of,Well Excavation Specifications ❑ Gravel Pack LD Tracy —f --Type of Casing ;U Domestic/Private Type of Grout Depth of Grout Seal R Other ❑ Delta f"1 Public Surface Seat Installed by I I Irrigation _ Approx. Depth i I Eastern state Work Done Q�F�Lji/ Type of Pump H.P. ! - ,. Repair Work Dane ❑ TYP � Sealing Material (top 50'1 (� Well Destruction ❑ Well Diameter -- Filler Material (Below 50'1 Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I:i REPAIRIADDITION i I DESTRUCTION I I'availabptiwi hin 200 feet.) if public sewer is 7 Installation will serve: Residence, Commercial .+ i Number of living units: Number of bedrooms 1 Water table depth Character of soil to a depth of 3 feet: ,_.r,- - apacit No. Compartments ❑ Type/Mfg F � Y_-;—=�--;r , SEPTIC TANK ; Method of Disposal PKG. TREATMENT PLT. ❑ t '-'T"`^� Property Line 1 Distance to nearest: fWeH _F.oundation" p Y 1 - Total length/size LEACHING LINE ❑ No. & Length of lines Property Line ❑ Distance to nearest: /Well Foundation. - FILTER BED Number SEEPAGE PITS V) Depth Size ; Foundation Property Line SUMPS Ll Distance to nearest: -Well DISPOSAL PONDS ❑ f 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, and 1 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 signature shat!not ation certifies the ersonin such a that s to n theeC rfoemancecof to he work for which ehis permlaws +s issued, shlalremp oy persons+stibjact to wori6g of arkman!sgCompensa I following: „ { tion laws of California." / i The applicant t r 1 regL1 s tions. Complete drawing on reVer d@ (/ Title: Date: Signed X y � - r FOR DEPARTMENT USE ONLY Date J Application Accepted by I Date Date Final Inspection by I Pit or Grout Inspection by - I Additional Comments: LJStk 466.6781 EI Lodi 369-3621 ❑ Manteca 823 7104 El Tracy 835 6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 CK RECEIVED BY DATE PERMIT'NO. FEE AMOUNT DUE AMOUNT REMITTED SH l INFO + EH 13-24 tRrv.o 954 �'��`-'" �iJQ [r EH 14-26 ��F