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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT f 1601 E. HAZE.i ON AVE., STOCKTON, CA I Telephone (209)"'466-6781 PERMIT EXPIRES 1"YEAR FROM DATE ISSUED (Complete in Triplicate) lication is ruct Application"is hereby mad /or install the work herit e to the San Joaquin Ordinance rLocal nce No.649 for sewage or permit No.1862 for wellldpump and the Rules and Regulations of he San Joaquin made in compliance with San Joaquin County. Local Health District. " 9 4 }. } PM City ,gn.TG,&,4 Lot Size '42 �} Lav i`�P - Job Address _ . �,./ �, Lou� S� 1��' Phone Owner's Name T'4� `,�L� ``�o/l Address • Y �9� Phone S z 3- License �/.Z/�✓ �, M T G�, License No. 7 DESTR OTHER ❑ Contractor's Name WELL REPLACEMENT ❑ NEW WELL ❑ - TYPE OF WELL/PUMP: -- - "—" SYSTEM REPAIR"0 INSTk TI N�� DISPOSAL FLD. PROP. LINE SEWER LINES � PITS/SUMPS DISTANCE TO NEAREST: SEPTIC TANK AGRICULTURE WELL OTHER WELL_.�� FOUNDATION �� INTENDED U E TYPE OF WELL PRO13L CONSTRUCTION SPECIFICATIONS Dia of Well Casing ❑ Open Bottom O Manteca Dia. of Well Excavation ❑ Industrial 4 Type of Casing Specifications 6 ❑ Tracy f ❑ DomesticlPrivate ❑ Gravel Pack Type of Grout F-1 Public ❑ Other ❑ Delta Depth of Grout Seal ` �� _--Approx. Depth❑"Eastern Surface Seal Installed'kty i ❑ irrigation State Work Done Repair Work Done ❑ Type of Pump �� H.P. Sealing Material {top'50'1 Well Destruction ❑ Well Diameter �� ,- ; Depth i Filler Maferial (Below 50'1 available-within-200 feet.) TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION ❑ (No septic system permitted if public sewer is Other Installation will serve: Residence `°•" Commercial } }- -;•";-, ! Number of Hving. nits: Number of bedrooms 1 Water table depth Character of soil t a depth of 3 feet Capacity No. Compartments " SEPTIC TANK [5" .Type/MfgMethod of Disposal 'b I I PKG. TREATMENT PLT. ❑ on Property Line '• Foundation _ # i Distance-to nearest: Well Total lengtblsiie �... LEACHING LINE , ❑" No. & Length of lines Property}'Line Distance to nearest: Well Foundation ❑ an �.� FILTER BED _•� _ ��. .._ -._"--• Z� -- - — ---- —_ - -- % r 1 /- Size Number SEEPAGE PITS ED] Depth p ' Property Line_�— Od Foundation SUMPS ,. Distanc j to nearest: Well .f DISPOSAL PONDS ❑ I hereby certify that I have prepared this applicationaand District.at he work will be done in accordance with S work for Joaquin this permit is iss ed, I shall not rules and regulations of the San Joaquin Locg- , Home owner or licensed agent's signature certifies the following- I certify that a the performance California."the rsons subject to workman's signal sa- employ any person in such manner as to n thbeGme subject ofotha work workman's c(chthis permittion is issued,I shall employ ape is hiring c subcontracting signature certifies the following:"I certify that performance tion laws of Ca1'ifornia." The applicant must 1 for all r aired inspections. Complete drawing on reverse side. Date- Title- Signed ate: AllTitle: } y Signed I ; F R DEPARTMENT USE ONLY � Q .� A.. i ©" Date rea Application Accepted by Date ! nal Inspection by Date Pit or Grout Inspection by. y ) Additional Comments: 0 Tracy 835- 1 ❑ 5tk 466 6781 ❑ Lodi 369 3621 " ; ❑ Manteca 823-71 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.D. Bax 2009, Stk., CA 95241 CK RECEIVED BY DATE PERMIT`Nd. FEE AMOUNT DUE ( AMOUNT REMITTED GASH INFO S�Za—1114 } +EH 13-24(REV.10163) EH 14-28 _ _