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4�/ 5 APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT ; 1601 E. HAZELTON AVE., sTOCKTON, CA .3ya U _:. Telephone (20� PERMIT EXPIRES 1-YEAR FROM 4ATE 1 SUED (Complete in Triplicate) applicationis con fort andlor i and the Rules and Regulations of the San Joaquin Application is hereby made n the San Joaquin Local Health District for a permit construct andlor install the work herein described. This app urn County Ordinance No.549 for sewage v made in compliance with San Joaquin ` + I Local Health District. C Q PM ---- g Lot Size 8 �h,\oh City Job AddressCC-?? 07-1Phone ! VMz_ (YmLN& Address r I Owner's Name N Fholte 1lw 0V �. License No...�,�-� 1 lm 6u, LNr Address �� S PEST TICTION.^❑, 1 Contractus � WELL REPLACEMENT ❑ I , NEW WELL ` OTHER'❑.. 4 y TYPE OF WELL/PUMP: SYSTEM REPAIR ❑ t r' r } PUMP INSTALLATION ❑ /, PROP. LINE �� DISPOSAL FLD:-= ` SEWER LINES s-�.--_—/ �.._.�..---rPITS7SUMPS I DISTANCE TO NEAR EST: SEPTIC TANK - - AGRICULTURE WELL OTHER WELL I FOUNDATION 1 1 i INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION 5P.ECIFIGATIONS pia. of Well Casing I - ~� t Dia. of Well Excavation w a ❑ Industrial Open Bottom ❑ Manteca Specifications -' ❑ Tracy Type of Casing j .DomesticlPrivate ❑ Gravel Pack }S type of Gr ut l Cl Other C1 Delta l Depth of Grout Seal , - M Public Sutface Seal Installed by I I irrigation J Approxi De9th f I Eastern State Work Done Type of Pump �- H.P. Repair Work Done ❑ i r r �� Sealing Material f top 50'1 .,,,,,,•�_._--.�...�.«-.-�..-�-••-�F- -'_-""' Well Destruction ❑ Well Diameter -- 1 Depth Filler Material (Below 50'1 - available within 2(x1 feet-! + l TYPE OF SEPTIC WORK:-'NEW l 1 REPAIR/ApD1TION I I DESTRUCTION l I (No septic system peeet.) d.if_publ sewer is Installation will serve: Residence Commercial , Other l Number of living units: Number of bedrooms - Water-.table depth t Character of soil to a depth of 3 feet: �. ``apNo. Compartments ❑ Type/Mf Ct i .f acity SEPTIC TANK g • Method of Disposal__'�� I I PKC. TREATMENT PLT. ❑ Distance to nearest: Welt Foundation Property Line4 j t Totallength/size j LEACHING LINE ❑ No. A Length of lines s ❑ Distance to nearest: Well Foundation `-Property Line` FILTER BED Number-- - -- -__ SEEPAGE-PITS--•-•-•----�-i I Depth •+_-'�Siza r -1" Foundation Property Line SUMPS � J�.�.L�_fDista'n`ce to nearest: Well 1 DISPOSAL?;PONVbS ❑ I hereby ceriify`thaC 11h5ve prepared this application aHealth District.nd that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is jissued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or u -cokmanting sign nsr certifies the following: "I certify that in the performance of the work for which this permit is issued, l shall employ p 1 tion laws of California." f f t The applicant must call for requjr d inspections. Complete drawing on reverse side Signed X I Title: v Date: FOR DEP RTf1RENT USE ONLY - Date Area Application Accepted by _ T.I_ +� n by Dat -..».r- �O i --•-•--�� """-`-"`""" i J i�.Final Inspectio Pit or Grout inspection by Date _ Additional Comments: Tracy 835 6385 ❑ Stk 466-6781 ED Lodi 369-3621 ED Manteca 823 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE K REC IVED BYjDATE kMIT'NO. INFO AMOUNT DUE AMOUNT REMITTED H +.EH 1321(REV.1/n 5) EH 14-2e