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APPLICATION FOR PERMIT'=. SAN JOAQUIN LOCAL HEALTH DISTRICT PERMIT NO. 1601 E. HAZELTON AVE_ STOCKTON-CA Telephone (209) 466-6781 71 DATE ISSUED PERMIT EXPIRES I YEAR FROM DATE ISSUED' x. . . (Complete in Triplicate) rein rApplication is hereby made otoisthe deninJoaquin Local wHealth h Distri n County p0 dinanceermit to cNo. 549tfor dsewage sorlNo. 1862rfor ewell/Pump described. This application and the Rules and Regulations of the San Joaquin Local Health District. Job Address 1. S4 . tTAI^J ,;; Subdivision Name Phone Z Z3 Address Owner's Name �" N � � Phone Contractor's Name License No. TYPE OF WELL/PUMP WORK: NEW WELL El REPLACEMENT ❑ DESTRUCTIDI PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER s SEWER LINES DISPOSAL FLD. PROP. LINE DISTANCE TO NEAREST: SEPTIC TANK OTHER WELL PITS/SUMPS FOUNDATION AGRICULTURE WELL INTENDED-USETYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial ❑Open'Bottom ❑Manteca Dia. of Well Excavation 'k ❑ Domestic/Private ❑Gra'vel Pack ❑Tracy Dia. of Well Casing ❑ Public x ❑Other ❑Delta Type of Casing ( ❑ Irrigation's �gJ �� + Approx. ❑ Eastern Specifications ❑Cathodic Protection Depth Depth of Grout Seal Geophysical if Type of Grout N ❑Other__w Surface Seal Installed by ' State Work Done lRepair Work Done ❑ Type of Pump H.P. I Well Destruction ❑ Well Diameter( Sealing Material (top 501 Depth r — Filler Material (Below 50') sewer TYPE OF SEPTIC WORK: NEW INSTALLATION U REPAIR/ADDITION ❑ (No septic tank or seepage Piavailableewithid if nu200cfeet.) is Installation will serve: Residence _ Commercial Other Number of bedrooms Lot size Number of living units: , Water table depth �1 Character of soil to a depth of 1 Capacity feet: No. Compartments ' � q SEPTIC TANK EDType/Mfg r Method of Disposal PKG. TREATMENT PLT. F-1 Type/Mfg - Capacity �_ SEWAGE SYSTEM Distance .to nearest: Well' i" Foundation Property Line DESTRUCTION Total length/size LEACHING LINE ❑ No. & Length of lines FILTER BED ❑ Distance toy nearest: Well Foundation Property Line DeP til �-._�._ Size Number t SEEPAGE PITS ❑ Property Line E Distance to nearest: Well --� r Foundation SUMPS U ! DISPOSAL PONDS ❑ e done in accordance with San Joaquin county I hereby certify that I have prepared this application and that the work will b ordinances, state laws, and_rules.and regulations of the San Joaquin-Local-Health District. Home owner or licensed agent's signature certifies the following: "I certify,t. ,in.the performance of the work for which this permit is issued, I shall not employ any person in,such manner as to became subject to workman compensation laws of California."i he Contractor's hiring or sub-contracting sinature certifies to the following:s"I certifyation laws than n tof rniaerformance of the work for which f this permit is issued, I shall employ persons The applic ust ca or 11 requi d inspections. Complete drawing on reverse de. Date: =Z� Title: Signed / Cf 2 FOR DEPARTMENT USE ONLY Area [9 . ❑ Stk 466-6781 C / Application Accepted by r yep Lodi 369-3621 �6i✓c k/>�'yo✓4I Additional Comments: Date Manteca 823-7104 fa det.r►-07 hell • Pit or Grout Inspection b f.A 4, ate ❑ Tracy 635-6385 O h Cf-1- 6 ! Final Inspection by F Applicant - Return all copies to: Environmental Health Permit/ ervices 1601 E. Hazelton Ave., P.O. Box 2009, St k., CA9 $` AMOUNT REMITTED RECEIVED BY DATE PERMIT N0. lr•s(7c�#{a r. FEE BASE AMOUNT DUE I+r fie' INFO L✓.'4 Wy 10/82 500 EH 13-24 REV. 10/B2 1 0 -26 " Q1"e0. leveled PiC.kd "'u"'WdIJ ��