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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781: iPERMIT EXPIRES TYEAR FROM DATE ISSUED (Complete in Triplicate) work herein to the San Joaquin Local Healtcation is h District for a permit to 1862 construct and/or instal; and the Runes and Regulations of the San. This r Joaquin' Application is hereby made 9 made in compliance with San Joaquin Cor ry Ordinance No.549 for sewage v Local Health District, {� d 1- ��TeLlr PM I -720 IiF,)(>A�_ pho-W6 City Lot Size k Job Address �� r• "� r i F' Q&l .�ca�ae[>s�a4 -done D, " N�Ru Address �s j31 Owner's Name - }, _ ��6 GAJ &q License No. 2y3 B Phone j ' Address DESTRUCTION ❑ Contractor WELL REPLACEMENT ❑ NEW WELL ❑ OTHER ❑ I` TYPE OF WELLlPUMP: SYSTEM REPAIR ❑ PUMP INSTALLATION ElDISPOSAL FLD. PROP. LINE ��— �- DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PITS/SUMPS WELL OTHER WELL FOUNDATION �— �F INTI NDED USE TYPE OF WELL PRo_8_�EM AREA CONSTRUC BION SPECIFICATIONS pia. of Well Casing ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Specifications 1:) Industrial ❑ Tracy Type of Casing ❑ pomestic/Private ❑ Gravel Pack Type of Grout Other Ci Delta Depth of Grout Seal i [`I Public Surface Sea[ installed by [ I I irrigation Approx. Depth I 1 Eastern State Work Done — ' H.P. Repair Work Done 1❑ Type of Pump Sealing Material atop 50'1 Well Destruction ❑ Well'Diam eter �--- Filler Material (Below 50'1 Depth- available within 200 feet.) .� TYPE OF SEPTIC WORK: NEW'INSTALLATION l REPAlR1ADDITION I ! DESTRUCTION I I (No septic system permitted if public sewer rs ' Installation will serve: Residence— Commercial_J*/ Other Number of living units: Number of brooms 'Water table depth 4` Character of soil to a depth of 3 Leet: S L Capacity— [.�__ NO ..Compartments SEPTIC TANK 01 Type/Mfg , �. Method—ol Disposal_ PKG. TREATMENT PLT. ClFoundation f�— Property;Line i t Distance to nearest: Well I Q ,�. Total lengthlsize� LEACHING LINE No. & Length of lines ' r Property Line r Foundation_ ---M ❑ Distance to nearest: Well - + FILTER BED i __�__ —.. Number I D�' i Z . f [ 1 epth Sire SEEPAGE PITS I r Foundation� Property Line SUMPS [Sii� Oistan to nearest: Well f { pISPOSAL PONDS El { 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state awl, a I certify that in the performance°f the work for which this permit is issued, !shall not rules and regulations of the San Joaquin Local Health District. signature k Home owner or licensed agent's signature certifies the ft to following: " Y employ any person in such manneras to t n thbec me lance of the work for which this permitws iss ed,fI shall lemploy persons"Contractrsubj sring ubject to workimansub tlscompensa 1 certifies the following: "I certify the pe J, ` lion laws of California.': The applicant m . Sor all re fired inspecti ns. Complete drawing on rev rse side. Date: i !___ Title: Signed X V 1 "fioFt E)FpAWTMENT USE ONLY ?7 t Date I Application Accepted b � r,�j� j� # Date__— ,Fina1_Inspection_b Date07'� Pit or Grout Inspection by - .siA° c� �E� f Additional Comments: p Manteca 823 7104 ❑ Tracy 835-6385 ❑ Stk 466-6781 ❑ Lodi 369-3621 Stir;CA-95201 Applicant.-Return.ali-copies-to:-Environmental.-Health-Permit./•Services-1601-E-4lezelton Ave.-P O�Box`204g% RECEIVED BY OATS PERMIT NO. FEE AMOUNT SUE j, Y AMOUNT REMITTED j yk rjNFO a. t 3o 90-4-S l - r EH 13-24 IREV.t . EH 14-20 - -