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e - m APPLICATION FOR PERMIT SAN JOAQULN LOCAL HEALTH DISTRICT 1601 E. HAZETON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM GATE ISSUED {Camplete in Triplicate) , This ior all the rk madcation is Applic n icpmplhance made to the San JoaquinnCounty 0 dinalHealth nce No.District49 far sewage orpermit No.1062 for construct eilldpump atnd the Rules and IRegutations o!he Sans Joaquin made Local Health District. y5�Lot Sizea� Ph 14iJ� city L�! pL4 91 Joh Address V J r (�/G'L.11l� S q •1 J,17/ P�), Phone Address - -�- Owne1's Name L -� r�ry/ I License No. - Jj, 0fli! �f1-i1�Addressf J {u' ,rte DESTRUCTION u Contractar72 WELL REPLACEMENT ❑ TYPE OF WELLlPUMP: NEW WELL OTHER ❑ SYSTEM REPAIR C � PUMP INSTALLATION ❑ c DISPOSAL FLD. PROP,LINE SEPTIC TANK — SEWER LINES — PITSISUMPS DISTANCE TO NEAREST: AGRICULTURE WELL OTHER WELL FOUNDATION �•.` CONSTRUCTION SPECIFICATIONS INTENDED USE 7YPEJ�P WELL PROBLEM AREA Dia.of Well Casing ❑Open Bottom >2 Manteca Dia.of Well Excavation ❑industrial r Specifications ❑Tracy Type of Casing 1�--r� �L { C1 Domestic lPrivate ❑Gravel Pack Depth of Grout Seal Type of Grou�r�' Other CJ Delta '-1 Public /,-QSurface Seal Installed ❑ Irrigation f�pprox.Depth ❑Eastern H.P. State Work Done _ Repair Work Done C] TYAe of Pump 1 Sealing Material atop 501 Well Desuructian ❑ Well Diameter -t3— Filler Material{Below 50.1 L) f�ni,fCfr,J Depth r . available within 200 feel,) TYPE OF SEPTI WORK: NEW INSTALLATION❑ REPAIRlADD1710N G pESTRUCTION❑ lNoave septic system permitted if public sewer is Installation will serve: _ Other serve: Residence— Number of living units: Number of bedrooms Water tablo depth Character of sail to a depth of 3 feet: Capacity No.Compartments SEPTIC TANK 0 Type/Mfg Method of Disposal S PKG,TREATMENT PLT.❑ Distance to nearest: Well Foundation. Property Line __.�� ^�...,,... 4 Total length/size All LEACHING LINE la No.8 Length of lines Foundation Property Line FILTER 13ED ❑ Distance to nearest: Well �--- Number Depth Size SEEPAGE PITS Foundation Property Line SUMPS ❑ Distance to nearest: Well DISPOSAL PONDS ❑ uin county ordinances,stats laws,and I hereby cenifY that I have prepared this application and that the work will be done in accordance with San Joaq FI and regulations of the San Joaquin Local Health District.g Home owner or licensed agent's signature certifies the follnwin I certify that in the performance of the work foersons subject r which this to wormit rkman s compensaissued,t shall t employ any person in such manner as to become subject to workman's compensation laws of California:'Contractor's hiring so worktractis c signature perfonce of the work for which this permit is issued,isI shall employ p certifies the fallowing:"I certify that in the P6 tion laws of California." The apple t must call for alt e�r s tions.Complete drawing on reverse side. Tit1A" Signed FOR EP SE ONLY �y � r-! �'.-7��3 Area a�1 _^� Date�--- Application Accep[ud b Date Date—Final Inspection b� f Pit or Grout Inspection by ---f - - - - ---- �`- -------- -- -- --- - - - - 935 6385 Additional Comment . f ❑Ma"lata-B23.7104 .❑Tracy Stk.,CA 9520t `Stk 466-6781 ❑Lodi 369- 2009, Applicant-Return all copies to:Environmental Health PermitlServices 1601 E.Hazelton Ave.,P.O.Box CK 11RECEIVED 8Y DATE PERMr1'N0. - EINFO AMOUNT DUE AMOUNT REMITTED CASH _ f✓ , _ r� ♦EH 17.24 IREV,r l a I EN 1414 -..• - .