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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 4 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 . PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ,.;4caapr.tt ,,Y„, tl (Complete in Triplicate) app,cation is permit to construct an install the work herein described.o�San Joaquin Application is hereby made to the San Joaquin Local Health District for a pe and the Rules and Reg made in compliance with San Joaquin County Ordinance No.549 for sewage or Na. 1862 for we111 pump Local Health District.r' , `I PM ' k City d Lot Size Job Address .I 1 17 ~ TT' Phone 4 E0 �, l� Address — `Owner's-Name ; , Phone f Address �J License No._�� 51 1 Contractor � _ DESTRUCTION ❑ NEW WELL ❑ WELL REPLACEMENT ❑ OTHER ❑ TYPE OF WELL/PUMP: SYSTEM REPAIR 11 N, PUMP INSTALLATION ❑ DISPOSAL FLD. PROP. LINE SEWER LINES — PITS/SUMPS DISTANCE TO NEAREST! SEPTIC TANK �— AGRICULTURE WELL OTHER WELL ` FOUNDATION TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS pia of Well Casing t INTENDED USE ❑ Man Dia.,of Weil Excavation _ __• .. . ” 6 ❑ industrial ❑ Open Bottom____ a__ - P_- Specifications "' °� �. ❑ Tracy Type of Casing 1 fj [I Domestic/Private ❑ Gravel Pack Type of Grout El other ❑ Delta Depth of Grout Seal ❑"PulSfic Surface Seal Installed by Y �gpprox. Depth Cl:Eastern ❑ irrigation H`P •'State Work Done Repair Work Done ❑ Type of Pump �-- a Sealing Material (top 50') l �s Well Destruction ❑ 'Well Diameter �� Filler Material (Below 501 .r Depth is y available within 200 feet.) TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ .REPAIRIADDITION ❑ DESTRUCTION septic system permitted if public sewer ijCommercial Other Installation will serve: Residence� } Number f b dreoms 1 , Water table depth G Number of living units: _ ., 1:111f `'1 { No. Compartments . Character of soil to a depth of 3.f( Capacity� ❑ Type/1091.! •f F SEPTIC TANKry � S �i�+S fi,i` Method of i) PKG. TREATMENT PLT. ❑ f Property Line—o� r t Distance to nearest: Well / _ Foundation— I Tota( lengthlsize r ❑ No. & Length of lines t i LEACHING LINE Foundation� —Property Line ❑ Distance to nearest: Well FILTER BED d Size Number SEEPAGE PITS ❑ Depth Foundation Property Line SUMPS E3Distance to nearest: Well DISPOSAL PONDS ❑ 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, an rules and regulations of the San Joaquin Local Health District. performance of the work for which this permit is issued, I shill not Home owner or licensed agent's signature certifies the following: "I certify that a the ' the rformance of the work for which this permit is issued,I shall employ persons subject to workman's compensa employ any person in such manner as to become subject to workman's compensation laws of California.' Contractor's hiring or subcontracting signature certifies the following-"I certify that pe L. �1/ , i tion laws of California." The ap lice t must call for all req d inspections. Complete drawing on reverse side. Date:Title: Signed , Signed P DEPARTMENT USE ONLY O t ` Date Area Application Accept d by Data Final Inspection by ! Pit or Grout lnspe n by Additional Comments: ❑ Manteca $23.7104 ❑ Tracy 83&6385 i ❑ Stk 466.-6781 ❑ Lodi 369-3621 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton i4ve., P.O. Box 2009, Stk., CA 95201 RECEIVED BY DATE PERMIT NO. FEE AMOUNT DUE AMOUNT REMITTED CA 1 INFO % N- 1..---_� + EH 13:24(REV.1/e5) ` EH 1428