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to • 3 APPLICATION FOR PERMIT r SAN JOAQUIN LOCAL HEALTH DISTRICT ' 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 I PERMIT EXPIRES 1 YEAR FROM DATE ISSUED E (Complete in Triplicate) i application is h District for a permit to construct and/or install the work hein desc Joaquin County Ordinance No.549 for sewage or No. 1862 for well 1pump and the Rules and Regulations of the San Joaquin Application is hereby made to the San Joaquin Local Healtreribed.This app made in compliance with San q Local Health District. D � City Lot Size PM Job Address RF9=i9 .gLE 1, © Phone Address I Owner's Name � i Phone �� 3yST�us a � License No.� Contractor DESTRUCTION ❑ r TYPE OF WELLIPUMP: NEW WELL 0 WELL REPLACEMENT ❑ SYSTEMyREPA`R ❑ OTHER ❑ ION PUMP INSTALLAT ` ISPOSAL FLD. PROP. LINE ----S-EWER-LINES— ai I DISTANCE 70 NEAREST: SEPTIC TANK AGRICULTURE WELL OTHER VNEL PITS/SUMPS FOUNDATION i I fi M I I INTENDED USE TYPE OF WELL P�08LEMAREA CONSTRUCTION SPECIFICATIONS Dia.lof Well Casingk i El Open Bottom ❑ Manteca Dia. of Well Excavation ` ` ❑ Industrial Type of Casing 5 Specifications �Z ! 4�Domestic/Private Gravel Pack ❑ Tracy Typ6 of-Grout �G ❑ Other :11 Delta Depth of Grout Seal t ❑ Public , i ' Surface Seal lnstahed tiy-� ❑ Irrigation ��pprox. Depth ❑Eastern i I1. ' H.P.— ` �'� � Com.\State r Vork'lDc6 Repair Work Done ❑ Type of Pump �`�� I j j �s.Sealing Material (top 50') Well Destruction ❑ Well Diameter -__- -.- Depth Filler Material lbel- 50'1 availabie within 200 feet.) TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPArI-IRIADDITION El DESTRUCTION• lNo-s�ptic'system 5a�mitted if public sewer�s ` - Y 5� j�.1 Commercial'—k ,,Other I }i f Installation will serve: Residence �i Number of living units: Number of bedroll ms Water tableFdepth i Character of soil to a depth of 3 feet: No. Compants rtme t ❑ Type/Mfg ._.i {...Capacity .._� i l SEPTIC TANK ( _ _ "Method of'Disposa! r " .- - i PKG. TREATMENT PLT. ❑ �-' Foundation�`"�.� Property Line�-- I Distance to nearest: Well, 1 i �- �n,:tr :��i��` 1 Total lengthlstze LEACHING LINE ❑ No.& Length of lines L, l IProperty Line FILTER BED Ll Distance to nearest: Well Foundation Size ❑ Depth 1� _ �'-:;` 1 Number SEEPAGE PITS Well �a FoundationI—� Property Line I SUMPS ❑ Distance to nearest: DISPOSAL PONDS ❑ hereby certify that I have prepared this application and that the work will be done I in ac�ordi nce with Sari Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Healt 11 District.g that in the performance of the wlork for which this permit is issued, I shall not Home owner or licensed agent's signature certifies;thOollowin I certify nsa employ any person;n such manner as to become subject to workman s'coinpen`_sation laws of California." Contractor's hiri g or sub-contracting signature. certifies the following: "I certify that in the performance►i of the work'for which this permit is issued,I shah employ persons s}bject to workman's comps tion laws of California." I ". f` The appAcant I f f all re 're 'nspeetions. Gomprete drawing on reverse siJill - r _ -Date: Tjtle: --� r + Signed - FOR DEPARTMENT USE ONLY r \ Area 1 Application Accepted ti. , --�` � � ��yy.//'' --Date�— Datek— LA Final Inspection by Pit or Grout inspection b t f Additional Comments: ❑ Manteca 623-7104 ❑ Tracy 835-6385 ❑ Stk 466-6781 ❑ Lodi 369 3621 Stk., CA 95201 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, CK RECEIVED BY DATE PERMIT NO. } FEE AMOUNT DUE AMOUNT REMITTED CASH a 1 + EH 1324(REV.1/a 5) INFO •� S OC? j r1414-28