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Well DestructioLU Well Diameter Sealing Material (top '50") Depth Filler Material (Below',50') ; �� ' TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION j (No septic-t—aWe or seepage pit permitted if public sewer is 1 �l APPLICATION FOR PERMIT available within 200 feet.) SAN JOAQUiN LOCAL HEALTH DISTRICT Installation will serve: Residence Commercial 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT N0. " Number of living units: Number Telephone (209) 4656-6781, Lot size Character of DATE ISSUED PERMIT EXPIRES I'YEAR FROM DATE ISSUED ✓ SEPTIC TANK Type/Mfg (Complete in Triplicate) r No. Compartments - Application -is hereby made o, to the San Joaquin Local Health District for a permit to construct and/or install the work herein Capacity described. This application is madein tompliance with San Joaquin County Ordinance No. 549 -for Sewage.or No. 1862 for well/pump SEWAGE SYSTEM and the Rules d Regulations of thelsan Joaquin Local Health District. Foundation Property Line Job Address wG' Subdivision Name tA La Owner's Name + Add ess Z 4 � d" Phone i L Contractor's Name cense No.-�' y. fl C{ S ' Phone y r / aQ cr-'-----�-7 .-.] TYPE OF WELL/PUMP WORK: NEW WELL TELL REPLACEMENT F DESTRUCTION • PUMP INSTALLATION [SYSTEM REPAIR �] -�- - _ - OTHER—E-_ DISTANCE TO NEAREST: SEPTIC TANK �SEWER LINES �� D'hSPOSRL.FLO. PROP. LINE a " HER LL FOUNDATION IG��'"7� AGRICULTURE WELL ' OTWE a.. PITS/SUMPS INTENDED USE TYPE OF WELL. PROBLEM AREA `_ CONSTRUCTION SPECIFICATIONS r J Indu rialpen Bottom Manteca Dia. of Well Excavation F�vmestic/Private Gravel Pack Tracy } Dia. of Well Casing a ;� Public Other ❑ Delta Type of Casing �J Li IrrigationDepthprox Eastern ' Sp� fications f - Cathodic ProtectionDepth-of Grout Seal 17 Geophysical LJOther TypJ of Grout Seal Installed by Surface , E�� P Repair Work Done ❑ Type of Pump - H. P, k !.State Work Done `1,1 Well DestructioLU Well Diameter Sealing Material (top '50") LEACHING LINE U FILTER BED ❑ No. & Length of lines Distance; to nearest: Well Total length/size Foundation Property Line SEEPAGE PITS ❑ Depth { Size Number SUMPS U Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will be done inaccordancewith San Joaquin county 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 that in the performance of the,work for which this permit is issued, I shalt not employ any person in such manner as to become subject to workman s compensation laws of California." Contractor's hiring or sub -contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall -employ persons subject to workman's compensation laws of California." The applicant t 1 for all r uired ins ec Complete drawing on reverse side. ` Signed X ��c_ Title: ® - Date: I FOR DEPARTMENT USE ONLY Application Accepted by Area d Stk 466-67 Additional Comments: . Lodi 369-3621 Fy Pit or Grout Inspection Date Manteca 823-7104 Final Inspection by Date L7 Tracy 835-6385 i 'Applicant} Return all copi Envir,nmenta Health Permit/Seryices,16 E. azeIton Ave., P.O. Box 2009, Stk., CA 95201 FEE—[ BASE AMOONT--dUE AMOUNTSREMITTED RECEIVED BY DATE PERMIT NO. INFO ]0/82 500 EH 13-24 REV. 10/82 14-26 1 V Depth Filler Material (Below',50') ; �� ' TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION j (No septic-t—aWe or seepage pit permitted if public sewer is 1 �l available within 200 feet.) ` Installation will serve: Residence Commercial Other " Number of living units: Number of bedrooms Lot size Character of soil to a depth of 3 feet: Water table depth ✓ SEPTIC TANK Type/Mfg Capacity No. Compartments - PKG. TREATMENT PLT. Type/Mfg' Capacity Method of Disposal �. f , SEWAGE SYSTEM Distance.to nearest: Well Foundation Property Line � nE5TRUCTION L -rte L LEACHING LINE U FILTER BED ❑ No. & Length of lines Distance; to nearest: Well Total length/size Foundation Property Line SEEPAGE PITS ❑ Depth { Size Number SUMPS U Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will be done inaccordancewith San Joaquin county 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 that in the performance of the,work for which this permit is issued, I shalt not employ any person in such manner as to become subject to workman s compensation laws of California." Contractor's hiring or sub -contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall -employ persons subject to workman's compensation laws of California." The applicant t 1 for all r uired ins ec Complete drawing on reverse side. ` Signed X ��c_ Title: ® - Date: I FOR DEPARTMENT USE ONLY Application Accepted by Area d Stk 466-67 Additional Comments: . Lodi 369-3621 Fy Pit or Grout Inspection Date Manteca 823-7104 Final Inspection by Date L7 Tracy 835-6385 i 'Applicant} Return all copi Envir,nmenta Health Permit/Seryices,16 E. azeIton Ave., P.O. Box 2009, Stk., CA 95201 FEE—[ BASE AMOONT--dUE AMOUNTSREMITTED RECEIVED BY DATE PERMIT NO. INFO ]0/82 500 EH 13-24 REV. 10/82 14-26 1 V