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APPLICATION,FOR PERMIT k SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE`7ION AVE.,",STOCKTON, CA Telephone (209) 466-6781 r, . PERMIT EXPIRES i YEAR FROM DATE ISSUED ; r (Complete in,Triplicate) G s iication is r o.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Application is hereby made to the San Joaquin Local Health District for a permit to construct andlor install the work herein described.This app made in compliance with San Joaquin County Ordinance,No. } Y Local Health District. st�f, ti ¢ 8r } ,F r v Lot Size PM "A City Job Address h _ +, � Address Phone � ' "' Owner's Name VAddress Q7 icense No., 2. t Contractor WELL REPLACEMENT ❑ DESTRUCTION El- TYPE TYPE OF WELL/PUMP: NEW WELL ❑ ,,�,�. ---�OTHER'❑ F SYSTEM REPAIR-0 .PUMP INSTALLATION-❑• """""""° tz . PROP. LINE DISPOSAL FLD 4. " -;7S-- DISTANCE DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES" — . FOUNDATION !� AGRICUL7URE`1NELL"" OTHER WELL PITS MPS _ - INTENDED USE TYPE OF WELL PROBLEM AREA t' CONSTRUCTION SPECiFlCAT10N5i Dia of Well Casing Dia. of Well Excavation fel ' EJ Industrial ❑ Open'Bottom ❑ MantecaManteca. „k�. Specifications 1 � ❑ Gravel Pack ❑ Tracy Type of Casing ❑ Domestic/Private <. -,Type of Grout ❑ Other ❑ Delta Depth of Grout Seal ❑ PublicILI Surface Seal Installed by ❑ Irrigationpprox. Depth ❑ Eastern c .,..�5tate Work Done ------ Repair Work Done ❑t Type of Pump We11 Diameter Sealing Material Stop 50'1 Well Destruction ❑ Filler Material (Below 50'! i Depth a. _ available within 200 feet.) (TYPE OF SEPTIC WORK: NEW INfSTALI.ATION G]�REPAIRIADDITIO DESTRUCTION ❑ [No septic system permitted if public sewer 1s t ' Other installation will serve: Resid*nce Commercial 9) Number of living units: Number of bedrooms / Water table depth Character of soil to a depth of 3 feet: No. Compartments ❑ Typal Mfg �' I Capacity — SEPTIC TANK 3 ^- JMethod of Disposal PKG. TREATMENT PLT.❑ .-3 r= Property Line + Well Foundation Distance'to nearest: _ ' � Total length/size LEACHING LINE No &Length of lines - property Line " 1 + Foundation FILTER SED ❑ Distance to nearest: Well %+ _ -� Size " Number SEEPAGE PITS Depth at Property Line SUMPS ❑ Distance to nearest: Wel! l DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will be done in accordance wrth'San Jaaqu�n county ordinances, state laws, and sP v F rules and regulations of the San Jshall not oaquin Local Health District. - � that in the- work for Home owner or licensed agent's manner, torbecome subject to wlogrkman'srtcompen ation lawsoof California." Contractor's rhir g or sub_contracting this Permit is issued, lsignature employ any person p ersons subject to workman's compensa- certifies the following:"I certify that in the rformance of the work for which this permit is issued,I shall employ p + tion laws of California." I - �� The app u�r s ctions. �C�drawing on re rse side. [// y r llca t m or u� '" �` Date: / ' I Title: Signed FOR DEPARTMENT USE ONLY 0 f _--�� � ��1� r4• Date Area Application Accepted by: a F- ..moi 4 L( Date L t Date r� Final Inspection by ` pi or Grout Inspectiofi � l C � ❑ Tracy 835-638.5 AdBitianal Cnmments:Y ❑ Stk,'46&6781 ❑ Lodi 369-3621 ❑ Manteca 823 7104 - Stk., CA 95201 en Applicant- Return all copies to: `Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Sox 2 , ! �. CK RECEIVED BY, DATE PERMIT NO - FEE AMOUNT,DUE AMOUNT REMITTED CASH INFO �- ro+ EH 13-24 MEV. /n 5t EH 14-28