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a i it s acs e APPLICATION TOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELLTON AVE., STOCKTON, CA "Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 4% (Complete in Triplicate) „ t to t and/or install the work cation is Application is hereby mh SanoJoaquthe in County Ord nan Ji)aquin lHealth nce No.District49 for sewage or 1No. 1862 forcwell/pump and the'Rules s and Regulations of the San gJoaquin made in compliance w r ._ ' - - Local Health District. _' b:�r fi t: Z. ' �J t J Lot Size PM LCity' Job Address v- Phone - Owner's Name Address "`" _Phone. �. f Address If `�� t "' License Contractor L- PTYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION`❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ 1 DISPOSAL FLD. PROP. LINE DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES 1 I FOUNDATION AGRICULTURE WELL OTHER WELL — PITS/SUMPS k a INl ENDED'USE T-YPE--OP'WELt "PROBLEM AREA CONSTRLICTION`SPECIFI'CATIONS" Dia. of Well Casing El Bottom ❑ Manteca Dia. of Well Excavation f ❑ Industrial ,.�. e rte, S 61fications 4 ❑ Domestic/Private 4 Gravdi Pack ❑ Tracy Type of Casing ❑ Delta Depth of Grout Se21. �+ f Type of Grout Z ❑ Public ❑ Other i � a ' '-` �" L i E. f ❑ Irrigation t� Ppro x• Depth ❑ Eastern Surface Seal Installed by H P State Work Done Repair Work Done rot Type of Pump - s. ' Sealing Material {top 50') Well Destruction lZ Well Diameter / i I Depth I Filler Material (Below 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION PAiR/ADDITION ❑ DESTRUCTION 0^avo septiwith tem perm litted if public sewer is Installation will serve: Residence Jcommercial Other " Number of living units: Numbert of bedrooms �' / 4 f ,.Water table depth'f Character of soil to a depth of 3 feet: - r� ,/� � �ry�� ` (? r �» Capacity/__fit+ n 'No- Compartments all SEPTIC TANK &--Type/Mfg - � — Method of Disposal PKG. TREATMENT PLT. ❑ J Distance to nearest: Well C) Foundation 1©- Property Line �: t r o r¢. .' h "?;� i Tota lengthlsize LEACHING LINE dl/Ro. Length;of lines& a ,. Property Lina Q ❑ .Distance to nearest: Well Foundation FILTER BED I I k.r,. Size f�umber t SEEPAGE PITS itiYfsepth t ��a t✓Pro art Line SUMPS ❑ Distance to nearest ;_WeII �Fqundatm P y DISPOSAL PONDS ❑ i 1 Hereby certify that I have prepared this application and that the vvo� ill be done k�din accardane with a Joaquin county ordinances, state laws,'and rules and regulations of the San Joaquin Local Health District. J j Home owner or licensed agent's signature certifies the following: 1 certify that in the performance of the work for which this permit is issued, I signature shalt not 1 employ any person in such manner as to become subject to wdrkman's comperisa•tioh laws;ofaCalifo�nia.'�`Contracto ns1subjecring t to wo�kman'fscompensa certifies the following: ' certify that in the performance of•th6 work for which this permit is issued, I shat!employ pe ti aws of California" ' t The app inust call for I uir i s ct amp ate drawing on averse sid 1 Jn dfeC Title: Date: Sign • FOR DEPARTMENT USE ONLY r. Date S- Area ..... Application Accepted by _' " F pf� Final Inspection by Da ate ta Pit r Grout Inspection by !� Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 F1 Manteca 823-7104 ❑Tracy 835-6385 Applicant Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.0..Box 2009, Stk., CA 96201 FEE AMOUNTJPUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. INFO k{ v� _ 5 o �� ; .+ EH`13-24(REV._t/F 5) EH 14-28'