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APPLICATION FOR PERMIT s { SAN JOAO.UIN'LOCAL' HEALTH DISTRICT 1601 E. HAZEL+ON AVE., STOCKTON, CA- Telephone (209) 466-6781A A� PERMIT EXPIRES 1 YEAR FROM DATE ISSUED [Complete in Triplicate) r . , ' � ' permit to construct and/or install the work herein described.This application is Application is hereby made to the San Joaquin Local Health District for a pe y. 1 Ordinance No.549 for sewage or No. 1862 fowelllpump and the Rules and Regulations of the San Joaquin made in compliance with San Joaquin County to a Local Health District. PM �r Lot Size Job Address it Phone AdOres s W 2 f -� Owner's Na f .[fir �49 phone ice nse No. lJf .� a"pJ _Addres DESTRUCTION ❑ Contractor WELL REPLACEMENT ❑ NEW WELL ❑ OTHER JW TYPE OF WELL/PUMP' SYSTEM REPAIR ❑ PROP. LINE PUMP INSTALLATION ❑ DISPOSAL FLD. SEWER LINES r� t, � �"OTHER WELL PITSISUMPS DISTANCE TO NEAREST: SEPTIC TANK- AGRICULTURE WELL- p FOUNDATION TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing INTENDED USE [3 Manteca Dia. of Well Excavation Specifications Q Industrial ❑ Open Bottom Type of Casing k ❑ Gravel Pack ❑ Tracy Type of Grout TI DomesticlPrivate ❑ Delta Depth of Gro�t Seal I ❑ Public. ❑ Other �Approx. Depth ❑ Eastern Surface Sealilns alled by I ❑ irrigation " State Work.Done of Pump H.P. Repair Work Done ❑ Type Sealing Material (top 50') i ~` Well Destruction ❑ Well Diameter �— Filler Material (below 5&), �} Depth DESTRUCTION ❑ (No septic system permitted if public sewer is } f available within 200 feet.) 111 TYPE OF SEPTIC WORK: NEW INS(ALLATION ❑ REPAIR/ADDITION Q N Other � 4t V Commercial� 1 Installation will serve: Residence ,. Number of living units: Number of bedrooms�— Water table depth I r Character of soil to a depth of 3 feet: Capacity` -No. Compartments SEPTIC TANK, -Type/Mfg - `` f a -Method,of Disposal -__ � _.+`,:�-.-..,:-'•3.5-. -,.J F PKG. TREATMENT PLT. ❑ >. Property Line - f Foundation J Distance to nearest: Well , Total length/size LEACHING LINE ❑ No. &Length of lines property Line r ❑ Distance-to nearest: Well Foundation�� FILTER BED Number SEEPAGE PITS CO Deptfi2 "' Size - ❑ Distance. nearest: Well .Foundation�.— Property Line T SUMPS _ t'. E- T ;M -, .---'-,`—DISPOSAL PONDS ❑ -4 I hereby certify that 1 have prepared this application and that theworkwill be done in accordance•with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health following: signature t. ` e sub'ect to workman's compensation laws of California." Cont pe rsons b or sub-contracting oworkman's' compensa- Home owner or licensed agent's signature certifies the followin I certify that in the performance of a the for which this permit o issued, I shat not employ any person in such manner as to been I certifies the following:-I certify that in the performance of the work for which this permit is issued, I shall employ tion laws of California." The applicant mut call for required inspections. Complete drawing on reverse side. Date. Title: 4 - .. Signed ' FO EPARTMENT US NLY p / 6 Date O Com' Area f✓ Application Accepted by —�0 Date Final Inspection b Pit or Grout Inspection byy Date . Additional Comments: ❑ Tracy 83`5-5385 ^ ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823 7104 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA V95201 RECEIVEDBY DATE PERMIT"NO. FEE AMOUNT DUE AMOUNT REMITTED C , INFO r ��gf gb "►S + EH 13-241riEV.1/esY ��` � �• EH 14-25 .-