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APPLICATION FOR PERMIT 1 . SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL i ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES i YEAR FROM DATE ISSUED (Complete in Triplicate) application is Application is hereby made to the San Joaquin Local Health District for a permit construct and/or install and the Rules and herein Regulationdescribed. s of fthe San Joaquin made in compliance with San Joaquin County Ordinance No.549 for sewage or No.o. 1862 for well p Local Health District. PM Lot Size O�� r + City . Job Address I J} (N� O 010, Phone LAO �:rltr�l Address - Owners Mame-{- � �,. . License No. DES C] Phone Address �� RUCTION 1 Contractor _ � WELL REPLACEMENT ❑ ! NEW WELL ❑ OTHER ❑ TYPE OF WELL'IPUMP: SYSTEM REPAIR ❑ PROP. LINE PUMP IN,'INSTALLATION ❑ DISPOSAL FLD. +� SEWER LINES --�- PITS/SUMPS M DISTANCE TO NEAREST: SEPTIC.TANK ��— OTHER WELL "3 r J }zt J F..OUNDATION AGRICULTURE WELL INTENDED USE TYPE OF WELL PROBLEM AREA`° CONSTRUCTION`SPECIFICATIONS Dia of Well Casing El Manteca Dia. of Well Excavation ❑ Industrial ❑ Open Bot tom -�,^x. Specifications Type Casing ❑ Grave ❑ Tracy l Pack Type of Grout ` ❑ Domestic/Private F1 Delta Depth-of Grout Seal ----------------- r Public ❑ Other --Approx. Depth I 1 Eastern Surface Saal InstaNad by P. t: State Work Done ` Work Done Type of Pump -� Repair I] - h CCK I Sealing Material (top-501 _ i S Well Destruction ❑ Well Diameter �— Depth ller Material IBelow;54'I k pESTRUCTION i I INo septic-systern-'permitted if public sewer is 1� TYPE 577EPTIC WORK: NEW INSTALLATION I i REPAI ADp17lON available within 200 feet.) i` Commercial Other — -- { Vistallation will serve: Residence— droom Number b '� Number of living units: � Water table depth Character of soil to a depth of 3 feet-. Capacity' ''�-'--�— No. Compartments 9 j SEPTIC TANK ❑ Type/Mfg Method of Disposal r PKG. TREATMENT PLT. ❑ } _Propel[ ,, Line 1 : Foundation Distance to nearest: Well Total length!size LEACHING LINE ❑ No. &Length of lines Property Line Foundation_�� t FILTER BED ❑ Distance to nearest: Well if I Size sNumber. f SEEPAGE PITS Iti ,Depth r f �-Property Line SUMPS L-1Distanceto nearest: Well 3f3Q Foundation I© DISPOSAL PONDS ❑ k Joaquin county ordinances, state laws, and I hereby certify that I have prepared this application Hcalt h�that work will be done in accordan a-with Sanwork for which this permit is issued, I shall not rules and regulations of the San Joaquin Local Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the w employ any pe arsons subject to workman's compensa- person in such mfr thaas to t in the perforemabcect to workman's he work for which compensation permitvis issued1fl shall employ plot's hiring or sub contracting signature certifies the following: "I certify I tion laws of California." _ _ __„ .-.� ,_ - �� i —The applica ust call f I re ired inspections. Complete drawing on rew� e��rsside T pate:... Titley I Signed X FOR DEPARTMENT USE ONLY f2 Area �f 1 l Date { Application Accepted by5� Date _ o Pi or Grout Inspection by Date '�1 Final Inspection by 1 Additional Comments: ❑ Manteca 823 7144 ❑ Tracy 835-6385 " Stk., CA 95201 Applicant- Return all copies to: � ❑ Stk 466-6781 ❑ Lodi 369-3621 i Environmental Health Permit/services 1601 E. Hazelton Ave.. P.O. Sox 2009, 1 CK RECEIVED BY DATE PERMIT'NO. FEE AMOUNT DUE AMOUNT REMITTED CAS41rv'�� ♦ EH 13-241REV.tins) INFO EH 14-26