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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL i ON AVE., STOCKTON, CA z Telephone 12091 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUE® ..,; {Complete in Triplicate} application is finance No. for sewage r No. 1862 for we and the Rules and Regulations of the San Joaquin Application is hereby made to the San Joaquin Health District for a permit to construct and/or install the work herein described.This 4 made in compliance with San Joaquin County Local Health District. c n ¢ PM City 9 `4d Lot Size Job Address " phone L v Address +, Owner's Name 7 Phone License No. Contractor's Name J WELL REPLACEMENT ❑ DESTRUCTION 11NEW WELL ❑ OTNER ❑ ` TYPE OF.WELLIPUMP: SYSTEM REPAIR ❑ It PUMP INSTALLATION ❑ �-(DISPOSAL FLD. PROP. LINE SEWER LINES PITS/SUMPS DISTA'NGE TO NEAREST: SEPTIC TANK � AGRICULTURE WELL OTHER WELL— FOUNDATION 1� INTENDED USE TYPE OF WELL PROBL�Ep CONSTRUCTION SPECIFICATIONS Dia of Well Casing ❑ Open Bottom ❑ Manteca Dia. of Well Excavation—�-- Specifications ❑ Industrial ❑ Tracy Type of Casing ❑ Domesticl Private ❑ Gravel}Pack Type of Grout ❑ Other ❑ Delta Depth of Grout Seal O E3Public Surface Seal installed by ❑ Irrigation �pp4ox. Depth❑ Eastern Sta4e Work Done�.��-�- J Type of Pump —� H.P. Repair Work Done ,, Sealing Material (top 50') Well Destruction ❑ Well Diameter �— Fill -a-�� Depth t Filler Material (Below 50') er is —�� mem permitted if'public sew available within 200 feet.) TYPE OF SEPTIG WORK: NEW IN§}ALLATION REPAIRIADDITION ❑ DESTRUCTION ❑ (No septic system Commercial— Other Installation will serve: Residence' depth d l Number of bedrooms -- Water table ep Number of living units: -� � Character of soil to a depth�f 3 feet: is Capacity r Z-- No. Compartments SEPTIC TANK t TYPe{1MJJf Method of Disposal PKG. TREATMENT PLT. ❑ IF Property Line's `i Foundation Distance to nearest: Well-�--- 1�. .r —=~— _ �� k, Total length,size i (�No. & Length of lines LEACHING LINE Property Line V; -T--Tr f: t Foundation y. � "_�. ,,,�� ,� �c� FILTER SED ❑ Distance to nearest: Well��— t Number i t SEEPAGE P1T5. Depth -Size ' �J ` Property Line �• I �. ', Foundation—�-- ti 1 SUMPS ❑ Distance to nearest: We�� _,_,,,,.--.......-.»-,-� _ DISPOSAL PONDS.Y ❑.__ - - t at'I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws,and , hereby certify th _ Health District- - rules and regulatl nd-t ions of the San Joaquin Local eeriifies the fol{ov�nng: "I certify that in the performance of the Contractoiork for w'slhir ngI op sub cont act nlsignlature� Home owner or licensed agent's signature rsons subiect to workman's compensa-7 employ any person in such manner as to become subject to workman's compensation laws of ed,California."I she certifies the following:"V cer[ify'that in the performance of the work for which this permit is issued,l shall employ p tion laws of California." L The applicant must call for all required inspections. Complete drawing on reverse side. a . ,� Date: ' �_> _O �► _ Title: Signed , } ~V FOR DEPARTMENT USE ONLY �r w Date Q� ".--g Area i ation Accepted by NJ f A t. Date t ate -�6'� Final Inspection by pit Grout Inspection by Additional Comments: ❑ Manteca 8237104. El Tracy 835.6385 ❑ Stk 466-6781 Q Lodi 369-3621 �. .�- Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95241 i RECEIVED BY DATE PE4iMIT`NO. CK � f FEE AMOUNT DUE AMOUNT REMITTED CASH INFO +€H 13-24 MEV.IWO � EH 1426 -