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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 + I PERMIT EXPIRES 1 YEAR FROM DATE ISSUED { (Complete in Triplicate) ribe ,This t application is Application is hereby made an the San Joaquin Joaquin County ordinance Local lHealth District for a for sewage or it to 1862 for well/dpuoinstall herein construct mp and the Rules and R gulations of the San Joaquin made in compliance with S q Local Health District ry g Q k ` S Lot Size ACVOKT'S PM City Job Address AG Phone. Address Owner's Name F �710 Phone Ar�44/�License No. '�..-- Contractor � Lt1�0 Address 7 Al, �DEQ � - DESTRUCTION ❑ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT L-1 SYSTEM REPAIR ❑ OTHER ❑ PUMP INSTALLATION ❑ SEWER LINES DISPOSAL FLD. PROP. LINE DISTANCE TO NEAREST: SEPTIC TANK �_� OTHER WELL PITS/SUMPS FOUNDATION AGRICULTURE WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS . TYPE OF WELL {l Casio � INTENDED USE T Dia. of We 9 ❑ Open Bottom ❑ Manteca Dia. of Well Excavation ❑ industrial Specifications t Type of Casing � ❑ Domestic/ ❑ Tracy Private ❑ Gravel Pack Depth of Grout Seal Type of Grout l-3 Other Cl Delta ; fl Public '" Surface Seal installed by 11 Irrigation ,A:ppro. Depth i I Easterh t 4'_- " - - --State Work-Qbne - H P. .' Repair Work Done ❑ Type of Pumpw. Sealing Material (top 50'1 Well Destruction ❑ Well Diameter�- �- : ".�©ePth•-�, Filler Materia! (Below 501 TYPE OF_SF WOfiK: NEWtINSTALLATION RLPAIR/ADDITION I 1, DESTRTUCTION I i alvailableseptlwi within 200 teec system p r ft`ed if public sewer is "# 4 ,� I - - — Installation will serve: Residence Commercial'/ Other �"X�ST/11�6" L® r 0 I i. Number of living units: ,Number of be �oms Water table depth V i Character of soil to a depth f 3 feet: I �/pT GC P9�L Capacity (�'.d— No Compartments SEPTIC TANK �YPe/Mfg ; Method of Disposal _ t PKG. TREATMENT PLT. ❑, iert l p 'pro Line ZQ2� 1 i" Distance�fd nearest: Well if 00 Foundation P Y - tai Total length/size` f LEACHING LINE No. & Length of lines 0 Distance to nearest: Well /BO Foundation,�� PropertyLine FILTER BED f 4 3 Size Number b 'Z SEEPAGE PITS' 3 * epth ..-- SUMPS 5'.lrCl 'Distance to nearest: Well �"u�Foundation gam Property Line 'r I , a -- DISPOSAL PONDS r❑L ;, — ' hereby certify that I have prepared Ihis.applicatioh^and that the work will be done in accordance with San Joaquin county ordinances, state laws, and f rules and regulations of the SanJoaquin Local Health Di$trict. Home owner or licensed agent's signature certifies-th.0following: 11 certify that in the performance of the work for which this permit is issued, 1 signatur shall not ornia." Cori employ any person in suchimanner tintthe performancecoIothe wok for which workman s th' perm Cis iss eiir;sation laws of l'fI SKAlf empl ty personslsubi subject to workmanring or 'scompensa- kcertifies the following:" Y tion laws of California." The applicant must call for all required inspections. Complete drawing on reverse tide. -7—.14-0 / `0 Title: & Date: Signed IX FOR P PARTMENT USE ONLY 4 q Date r Area .Application Accepted by l Date Final Inspection by n.®7-� Date /.�/?�� � Pit or Grout tnspectirsn by''�_ r T� t� Additional Comments: 835 6385 ❑ Stk 466 678'1 f_I❑Lodl 369-3621 ❑ Manteca 823-7104 racy Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, 5tk., C'9 � ani . # rY � P4 6� _ 1ev CK RECEIVED BY DATE PERMIT'NO.' �f FEE AMOUNT DUE AMOUNT REMITTED CASH INFO +.EH13-24(REV.IiH5) EH 14-26