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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE.,. STOCKTON, CA ` Telephone (2O9) 466.6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED K j 4 (Complete in Triplicate) "- -� hcation is n is hereby 54 for sewage or No. 1862 for well Pu and the Rules and Regulations of the San'Joaquin Application made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This app AZA Pp l made in compliance with San Joaquin County O 3Q.�Local Health District. PM City �rG Lot Size ; Job Address i t Phone I e./ Address Owner's Name ------ -~~-"-", '". -- License No. phone Y �.--M Address .DESTRUCTION ❑ I Contractor WELL REPLACEMENT ❑ t' <. --—.m- .'NEW NIELL--�❑ _ -- -. - — 'ROTFiER ❑"'� ,...,..,�..,�- TYPE OF WELL/PUMP: Q-_"' SYSTEM REpPIR O PUMP IN ... ATION ❑� DISPOSAL FLD. PROP. LINE SEWER LINES ---- PkT515UMPS i DISTANCE TO NEAREST:,SEPTIC TANK —�~ AGRICULTURE WELL OTHER WELL FOUNDATION -- - , '.�.__--� -- — —T1'FE OF,WELLPROBLEMi4REA �`�CONS7RlfCTION SPECIFICATIONS i Dia. of Well;Casing INTENDEDUSE "'-" p Manteca — Dia, of Well Excavation L] Industrial i' ❑ Open BottomI Specifications l ` ❑ Tracy Type of Casing ❑ pomesticlPrivate n Gravel Pack {Type of Grout M.,Detta I Depth of Grout Scall[-I Public f_-1 Other _ Q fApprox. Depth I I Eastern Bullate Seal installed by i I 1 Irrigation r H.P. State Work Done _i Repair Well Done ❑ Type of Pump ' 1.`.,--,�..---„ Seating Material�ltop Well Destruction ❑ Well Diameter �—�- Filler Material (Below 50') Depth Filler +Nithiri"200 feet.) TYPE OF SEPTIC WORK: NEW ....... AJJION I REPAIRIADDITION I ! RE5TRUCIION I l INo septic system permitted iI•public sewer is =' Commercial Other installation will serve'.' Re dente I 1 Number of drooms Number of living units: Water table depth Character of soil to a depth of 3 feet: n re. Capacity._ — No.-Compartments SEPTIC TANK 0"'Type/.,Mfg f Method__Of ZDiis�p9sal PKG. TREATMENT PLT. ❑ Foundation __�0 .Property Line Distance to nearest: Well . Totallength/aIle LEACHING LINE No. 81 Length of lines i a` Foundation j Property.Line t FILTER BED ❑, Distanca'to nearest: Well i Number Si SEEPAGE PITS l I Depth) ze Property Line SUMPS 'L1' Distance-to-nearest: Well " Foundation" r R DISPOSAL PONDS 7 ' �♦ i hereby certify that l have prepared this application and -that the work will be done-in accordance..with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. that in the work for Home owner or licensed agent's signature certifies subiect Ito wkorkman'srtcoympensation Iawsoof Californiah" Contract r'srhiri gI or sub-contracs permit is ting nglsignatuore employ any person"in such manner as to be a sans subject to workm 's compensa- 1 4 certifies the following:�'I certify that in th"e-per#ormance of-She work torr which-this peYrnit is issued, I shall erne oy p i A r tion laws of California." _ f The applicant must call for all requi d spections. Complete drawing an reverse side. Date, Title: Signed X I FOR/�pRTMENT USE ONLY Z Date Area h Application Accepted byDate �Sr I. Date Final Inspection by Pit or,Grout Inspection by Additional Comments: ❑ Lodi 369-3621 ❑ Manteca 823-7104 (J Tracy 835-6385 ❑ Stk 466-6781k., CA 95201 Applicant- Return all Copies to: , Environmental Health PaimitlServices 1601 E. Hazelton Ave.,, P.O.P.P.O. Box 2009, DATE PERMIT NO. FEE AMOUNT:DUE AMOUNT REMITTED CASH RECEIVED BY INFO a.EH 13-24(REV.t/R 5) - EH 1420 r _ 1