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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (2a9) 466-6781 PERMIT EXPIRES 1'YEAR FROM DATE ISSUED t (Complete in Triplicate) application is on is heie x r sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Joaquin Local Health b made to the San JoDistrict for a permit to construct andlor install the work herein described. This I Application y made in compliance with San Joaquin County Ordinance No- Local Health District, itg r City Lot Size Cd r� PM i p� w Job Addressr i phone �� I fi 1 z Address Owner's Name r Phone r/ , {-ed. License No. — Address DESTRUCTION ❑ Contractor WELL REPLACEMENT ❑ �fEW WELL LJ WELL ❑ k TYPE OF WELLIPUMP: SYSTEM REPAIR D PROP. LINE PUMP INSTALLATION L] DISPOSALFLD. ` SEWER LINES PITS/SUMPS DISTANCE TO NEAREST: SEPTIC TANK —rte AGRICULTURE WELL _�— OTHER WELL FOUNDATION �� I TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia of Well Casing } INTENDED USE �� Dia. of Well Excavation F ❑ Open Bottom ❑ Manteca Specifications ❑ Industrial El Type of Casing Cl Gravel Pack Type of Grout ❑ Domestic!Private Depth of Grout Seal _ �- Cl Other � Ll Delta = k ['l Public Surface Seal installed by I I irrigation Approx, Depth 4 I Eastern State Work Done I H.P. Repair Work Done ❑ Type of Pump -- Sealing Material (top 50'1 Well Destruction D Well Diameter Filler Material IBelow 50'1 Depth public sewer is I REPAIRlADDITION I I DESTRUCTION I I (No septic system permitted if p r available within 200 feet.i I TYPE OF SEPTIC WORK: NEW IN TALtATIONl 1 Commercial Other , k installation will serve: Residence I Number of living units: Number of bedrooms ,M Water table depth Character of soil to a depth of 3 feet: Capacity_,\.gc 0 No. Compartments r SEPTIC TANK TYpeLMf9 Method of Disposal Pr r [�\ / PKG. TREATMENT PLT-.0 0)'—_ Foundation Property Line_�--- Distance to nearest: Well ld s • Total length)size F LEACHING LINE HT1 No. & Length of lines i r a} Foundation — Property Line FILTER BED D Distance to nearest: WellCL I 11 // "7 C� Size � Number SEEPAGE PITS Depth Foundation property Line ` SUMPS Ll Distance to nearest: Well-� ---- DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District.g that in the work for t Home owner or licensed agents signature to become subjectlto workman's ooympensat on laewsoof California."Contractor srhir ng arr suh con act ng s griatuthis perrnit is issued, I shall �e employ any person-in such mannerpersons subject to workman's compensa 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." !I lica ust call fo, r gwred inspections. Complete drawing on reverse side. The apQ rrt Date: Title: t Signed X i FOR DEPARTMENT USE ONLY Z Z3� 4 1 p ` Date Area Application Accepted by y l Date P. er Grout Inspection by �Date 5S---!-22-47Final Inspection b� r n Additional Comments: 835-6385 r D Stk 466-6781 ❑ Lodi;€369-3621 ❑ Manteca Services E. Tracy 835 Ave., P.D. Stk., CA 95201 i Applicant- Return all copies to: Environmental Health.permitlServices 1601 E. Hazelton ., P. Box 2009, +� CK RECEIVED BY DATE PERMIT NO. FEE AMOUNT DUE AMOUNT REMITTED INFO r7 'd�5(� � -2 � ..EH 1324 IREV.i/R 51 0 - EH -EH 14-26 T... . .