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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT "; 1601 E. HAZELTON AVE., STOCKTON, CA - w Telephone (209) 466-6781 ;ta PERMIT EXPIRES 1 YEAR FROM DATE ISSUED _°.;_`. (Complete in Triplicate) lDistrict rk herein described. This hcation is Application is hereby made to the Usnjougui Ordinance Local l 549 for sewage or permit 1862 for cwe{tlpump and the Rues and Regulations of he San Joaquin made in compliance with San Joaq g Local Health District. 4J 3 - f' ' s�°/Us 'i City —.. Lot Size PM Job Address Address f Phone �ll Q�w Address z Owner's Name �� 1 �r I Lscense No..7�----Phone Contractor Address DESTRUCTION ❑ } NEW WELL ❑ _WELL.REPIACEMENT_C]_ � :. _ sTYPE OF WELL/PUMP: SYSTEM REPAIR ❑ OTHER ❑� ~ PUMP INSTALLATION ❑ SEWER LINES -�--- DISPOSAL FLD. PROP. LINE DISTANCE TO NEAREST: SEPTIC TANK , OTHER WELL PITSISUMPS FOUNDATION # AGRICULTURE WELL l TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS x INTENDED USE Dia. of Well Casing Cl Open Bottom ❑ 'Manteca,,' Dia. of Well Excavation k ❑ Industrial ,. , i _ - w Specifications f Type of-Gasing"- -- .❑ Domestic/Private ❑ Gravel Pack ` ❑ Tracy T- VP v Type of Grout t ❑ Other ' !. : F1 Delta Depth of Grout Seal M Public -Approx. Depth l I Eastern Surface Seal Installed by II ! Irrigation H.P. State Work Done _ F Repair Work Done [2 Type of Pump r�, -ealing Material (top 50') 'Well Destruction ❑ Well Diameter -Filler Material (Below 50'1 Depth :4 per r ab TYPE OF SEPTIC WORK: NEW INSTAL�TION: "•REPAIR/ADDITION I I DESTRUCTION I I alvailseptile w thin system feet.) if public sewer,is Installation will serve:' Residence�✓ Commercial' +"a 'Other j Number of living units: Number-ot bedrooms y Water Sable depth Character of soil to"a depth of 3 feet: No. Compartments 2 V x , .vC. +, Capacity SEPTIC TANK '" .:,�>'fTypelMfg; �� _ ,. ( Method of Dispoal C PKG. TREATMENT PLT.❑l _, �' �I `-� 1 Foundation. Property Line f r LLDistance to nearest: Well r � total length/size LEACHING LINE No. & Length of lines �� Foundation "— Property Line 'FILTER BED Distance to nearest: Well Number.. !SEEPAGE PITS l 1 Depth Size Property Line SUMPS Ll Distance to.nearesV Well Foundation DISPOSAL PONDS ❑ -` �{ hereby certify that I 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. i cHome owner l ions od agent's signature certifies the following: "I certify that in the.performance of the work for which this permit is issued, 1 sig shanature ll not lemploy any person in such manner as to become mancecof he work for whit to workman's chethis permit is issuednsation laws of , I hall employ pefornia,, rsons�subject to workman's ring or compensa- 1� (certifies the following:-I certify that in the pe 1J tion laws of California." - 'The applicant must call fOrO re uir inspect.0 Complet6 drawing on reverse side. i Date: t ;Signed X Title: I s FO DEPARTMENT USE ONLY i Date Area 1 Application Accepted by - f t -Final Inspection by Date 4 Pit or Grout Inspection by Date - _- - ¢ (Additional Comments: - ❑ Stk 466-6781 ❑ Lodi V368-3621 CIManteca 823 7104 ❑ Tracy 835-6385 b Applicant- Return all copies to: Environmantal Health Permit/Services 1601 E:Hazelton Ave. P:O.'Box 2009, Stk., CA 95201 F CKRfCEIVED BY DATE PERMIT NO. t FEE w AMOUNT-DUE, AMOt1NTREMITTED ,- ''CASH ¢' INFO + EH 13.24 IREV.I I N 5) 0. EH 14-26 "