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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT s 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) 41 District for a nstall the work Application is hereby made to the Joaquin County Local nae Ntalth permit construct and/or . This o.549 for sewage orNo. 1862 forwe I/pumlherein p and the Rules andR Regulations application of the SanJoaquin made in compliance with q Local Health District. Loi Size R � f �! _ City C DCG PM E�-�S Job Address / rt'� rDRC-S�/ti�- Phoneg'� Owner's Name Address jr - -- - 3&9-a77 ._._,..rev..._, - Ic. �/_.,,_..-a--�..� -.,.�..-•��--1�� ,� Phone_ Contractor - N Address r I•-� � license No.��3-- # NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ 'TYPE OF WELL/PUMP: OTHER ❑ PUMP INSTALLATION SYSTEM REPAIR'❑ 1 DISTANCE TO NEAREST: SEPTIC TANK �� f� SEWER LINES DISPOSAL FLD. PROP. _ �__ AGRICULTURE WELL OTHER WELL PITSISUMPS LINE S TSI � FOUNDATION .. INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ;t Dia. of Well Casing ❑ industrial bCOpen Bottom ❑4Manieca y Dia. of Well Exca^�vation I Specifications Type of Casing IP(Domestic/Private ❑'Gravel Pack ❑ Tracy Ll Delta "` ! ;' Type cif rout a- I {'1 Public Il Other Depth of Grout Seal f � _ I r Sn A- I I Irrigation c_WApprox. Depth i I Eastern Surfaco $eel Iristalled by EH,P. _ State Work Done _ Repair Work Done [2 Type of Pumps — , Sealing Material 50' `� ;Well Destruction ❑ Well Diameter g l I fY i i vDepth 1. Filler Material (Below 50'1 k { TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I--DESTRUCTION I I aNailabperwithin 200 fe tided if public sewer is i Installation will serve: ,.Residence_ Commercial Outer .Number of living units: Number of bedrooms t. r _ Water table depth In '—C-haractef-of-soil-to-a-depth-of-3-feet: - _ ---- -—� VNo. Compartments SEPTIC TANK ❑ Type/Mfg Capacity__�x " YMethod of Disposal PKG. TREATMENT PLT. ❑ { Property Line Distance to nearest: Well Foundation ' �� i t Total length/size LEACHING LINE ❑ No- & Length of lines , i FILTER BED ❑ Distance to nearest: Well Foundation Property Line r SEEPAGE PITS l I Depth Size _ Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ ! hereby certify that I have prepared this application and tfiat'tlie`work will be done in accordance with San Joaquin county ordinances, state laws, and t rules and regulations of the San Joaquin Local Health Di§frict. l e following: "1 certify Home owner or licensed agent's signature certifies thtify that in the performance of the work_for which this permit is issued, I shall not compensation laws of California." Contractor's hiring or sub contracting signature employ any person in such manner as to become subject t&workman's certifies the fallowing: "I certify that in the performance of the work for which this permit is issued, I shall employpgrsons subject to workman's compensa- r tion laws of California." I_ { i The applicant ust call for all required inspections. Complete drawing on reverse side. f O e: Titl Signed .. r, 4 Date: I R DEPARTMENT USE ONLY Date-A U.�'�_, n Area Application Accepted by Dant /' Final Inspection by Date/J-0--a -- .. Pit or Grout inspection by - 71A 4 - Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 E0-Manteca= a23-7104 +y ❑-Tracy r�835-6385 `.� , r Appticant Return all copies to: Env lronmentehHealth -1601-E.`Naiefton Ave., P.O. Box 20Q9, StkA 95201 !FE*A CK RECEIVED 8Y DATE PERMIT'NO. MOUNTDUE AMOUNT REMITTED CASH EH 13-24(REV.I/n5) �� EH 14-26