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APPLICATION FOR PERMIT n SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone 1209) 466-6781 .PERMIT EXPIRES 'i YEAR FROM DATE ISSUED (Complete in Triplicate) .This application is /or install the work Application is hereby made to the San CJoaquin Local Health ounty Ordinance No.District 549 for sewage or permit Noa 1862 for we Local and the Rules and IR gulations of he Sanl Joaquin made in compliance with San Joaquin Local Health District. F _ PM Lot-Size'.` "� li 1 Job Address ` Phone _ t i Address Owner's Name t i. i •. Phone +' icense No, Contractor's Name WEtIkCEMENT F3 DESTRUCTION Elxi� 1 l TYPE OF WELL/PUMP: NEW WELL Q + OTHER ❑ - PUMP INST., ❑ SYSTEM REPAIR ❑ _ __� DISPOSAL FLD. PROP. LINE DISTANCE TO NEAREST: SEPTIC TANIKtt SE RLI 1yES PITS/SUMPS , i- . .....--�3 .FOUNDATIONS: ' -AGRICUL�U&,W_ELL OTHER WELL ' TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS E INTENDED USE �— Dia. of Well Casing I ❑ Industrial 1 Cl'Open Bottom ❑ Manteca Dia �of Weil Excavation Specifications } T44,of Casing ` ❑ Domestic/Private ;�Gravel Pack Q Tracy Type of Grout ❑ Public ❑:Other ❑ Delta Dept of,Grout Seal I -!—Approx. Depth ❑ Eastern Surface SealI.NT, d by I ❑ Irrigation ?. r State Work Done b... .�� H:P. Repair'Work DoneV❑_fYpe oaTTi m�'` 1 Sealing Material )top 50 M Well Destruction ❑ Well Diameter Depth - Y 4 Filler Material SBelo 1 _ATIavailable within 200 feet.) 1 � TYPE OF SEPTIC VIlORK:'�`NEW.INSTAIrON Q- RE�AIRIADDITIO DE57RUC71ON.❑ {No septic system permitted if public sewer is 4 , °VI f installation will serve: Residence Commercial other `r r. e, y er oms Number of living units: Number of d F J '� IPI Water table depth I { Character of soil to a depth`of-3'feet: Capacity ' No. Compartments SEPTIC TANK Q Type/Mfg Method of..Dlsposal if O s a 1' � r r PKG. TREATMENT PLT. Foundation` Property-Liffe f i pisiance to nearest: Well TotaNngthlsize "No:& Length of lines - LEACHING LINE f ,E ,� Property Line Q Distance to nearest: Well Founda�ion E FILTER BED Size °Number SEEPAGE PITS Depth J i �� Property{Line r ❑ Distance to nearest: We11 Foundation SUMPS { F' ; r DISPOSAL PONDS ❑ ` E I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, an rules and regulations of the San Joaquin Local Health District. that in the performance of the ework for which this permit is issued, i shall not Home owner-or licensed agent's signature certifies the following: "I certify arsons subject to workman's compensa- Home any person n such manner pato become subject to workman's oompensatiorl,laws of California."Contractor's hiring or sub contracting signature certifies the following:"l certify that in the performance of the work for which this permit is issued;l shailemploy p tion laws of California." applicant st for requir spections. Cc plate drawing an reverse side. f The app` x Date: ! Title: Signed X - FOR DEPARTMENT USE ONLY sF Date �� Area Application Accepted by *' '1 Pit or Grout inspection by I � � tiDate Data Final inspection by ti Additional Comments: ❑ Manteca 823 7104. ❑Tracy 8356385 E3 Stk 466-6781 0Lodi 369-3621 Environmental Health PermitlServices 1601 E. Hazelton Ave., P.O.Box 2009, Stk., CA 95201 Applicant- Return all copies to: E. 1 ft CK RECEIVED BY DATE PERMIT"NO. FEE AMOUNT DUE AMOUNT REMITTED CASH INFO `'' + EH 13-24(REV.10/831 EH 14-28 ..