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1 APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE.,.STOCKTO , Telephone (209) 466-6781 _ :► ',PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ,� .. (Complete in Triplicate) , .. ical H It 549 for sewage or No. 1862 for.well/pump and the Rules-and Regulations of the San Joaquin Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein desc�bed.This application is PP t made in compliance with San Joaquin County Local Health District. F,t ,Y_ - s,. .. PM -" 4 City $G�1`—" -- Lot Size Job Address # - ,� t11/ C.•Q!---Phone. Address 1 r Owner's Name r Phone r �� t License No. I Address Contractor DESTRUCTION D :i NEW WELL--q WELL REPLACEMENT ❑ TYPE OF WELLlPUMP: �t .t.; OTHER ❑ SYSTEM REPAIR "❑ � PUMP INSTALLATION ❑ DISPOSAL FLO._ PROP. LINE DISTANCE 70 NEAREST: SEPTIC TANK �— SEWER LINES �— 711-1- i PITSSUMPS DIST AGRICULTURE WELL OTHER WELL FOUNDATION �� TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing INTENDED USE ❑ Man — Dia. of Well Excavation ❑ Industrial a Open Bottom. Specifications UJ I, Type of Casing i ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Grout O Other 11 Q Delta Depth of Grout Seal ❑ Public 'i` Ca Surface Seal Installed by ❑ Irrigation �Approx. Depth "Cl Eastern . State Work Done Repair Work Done ❑ Type of Pump Sealing Material Itop 50'1 Well Diameter - i" '''1 Well Destruction ❑ Filler Material (Selo 50'1 i Depth rmitted ifi.;public sewer is available within feet.! TYPE OF SEPTIC WORK: NEW INS ALLATION ❑ REPAIR/ADDITION DESTRUCTION ❑ INokse a systeW Pei t Other WAfeet.) installation will serve: Residence 3L- Commercial r, + Number of bedroomst n Water table depth. Number of living units: a;.Number f �q �-,�� } Character of soil to a-depth; 3-feet:- G n & Capacity— sz-`0— No. Compartments E3 Type/Mfg # Method of DisPOsal f. SEPTIC TANK loc"1 � 3 gip'^ ; f t '�A " PKG. TREATMENT PLf""❑ Property Line 1150 � Foundation�j Distance to nearest: WeII" _ q. b, ( - dotal length)size LEACHING LINE '�Q� O-f;<`Length of-lines f Property,Line 1— t �_ Foundation FILTER BED, ❑' Distance'fo nearest: Well `— _f A _ Size Number Depth � _ r SEEPAGE PITS s Property Line�— Well Foundation 3 SUMPS ❑.� Distance to nearest: � - DISPOSAL PONDS ❑ t I 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 errnit is issued, I shall not rules and regulations of the San Joaquin Local Health District. gwork for which this Home owner person licensed hagent's mannerassignature become subjects to workman's compensation l: "I certify that in the aws Californiahe Contractor'sns subjehieing ct to worksub-conman'sco signature employ any person in such m t certifies the following: "1 certify that in the performance of the work for which this permit is issued,I shah employ pe 1 tion laws of California." _„._ t The applicant'!must call for al required inspections. Complete drawing on reverse side. Date: 1 'w Title: Signed X ? r FOR iDEPARTMENT USE ONLY + Date I Application Accepted by � 2 pate Date Final Inspection by F Pit or Grout Inspection l I Additional Comments: ❑ Tracy 835-6355 " ❑ Stk 466-67_81, ,r0--Lodi,,,369:3621,,s. ❑ Manteca 823-7104 Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 Applicant - Return all copies to: Environmental ' CK RECEIVED BY - DATE PERMIT'NO. FEE AMOUNt DUE AMOUNT REMITTED CASH s INFO + EH 1324(REV.i/H 5) EH 1428