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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1YEAR FROM DATE ISSUED y a (Complete in Triplicate) il the work herein cation is Application madecnh omplliance with Sano the Joaquin County Ord n Joaquin fisnr3*A51549ior sewage or No.IB62 for w�aitiipump aHealth District for a permit to constructnd the Rules and Regulations of he Son t Joaquin Local Health District. '•` // G.•,_ � ��' �i + �r.f s ` J City " Lot Size PM Job Address //•j�1 /�f �� / L�,�/ ,// r } ^XJ / �'" i•a•��+Q .tJ��Y VAdd�e L'J' (O L1��•+i V Phone Ot4ne(s Name !V/ r/? / k Phone Na-- I Address ' License No. O 1 Contracts DESTRUCTIO NEW WEL-L-O- —:,-: WELL REPLACEMENT ❑ •I l TYPE OF�ELL/PUf"1P• +` SYSTEM REPAIR 13 ',PROP. O G PUMP tNSTALLATtON ❑ ,.,,rr "i'' pgpp, LINE j <5EWER LINES DISPOSAL FLD. t4 ' } DISTANCE TO NEAREST: SEPTIC TANK j3S OTHER WELL �� J PITS/SUMPS.— FOUNDATION AGRICULTURE WELL 3 ! INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS �, n_ y Y Dia. of Wall CasngJ •_ ❑ Industrial ❑'Open Bottom ❑ Manteca pia. of Weil Excavation Specifications C] Domestic!private ❑ Gravel Pack ❑Tracy - Type of Casing - i M Public Cl Delta Depih;of Grout Sal f Type of Grout_ - Other 1 i I I irrigation (Approx.,Depth I i Eastern Surface Seal Installed by + k � H.P. ( 1 State Work Done r Repair Work Done ❑ Type of Pumps I + I Sealin Material (top 5o'l Well DestrViOnn ❑ Well Diameter b g M Depth `i Filter Material(Below 509 fin(110 TYPE OF SEPTIC WORK: f NEW INSTALLATION 11 REPAIR/ADDITION DESTRUCTION I I available tw thin 200 feetned it public sewer I= A• ; � 17 { i Installation will serve: Re&dance_ 'Commercial_ Other ^� �', r r Number of bed l Number of living{snits: _. { Water table depth Character of soil tda depth of-3 feet: SEPTIC 'ANK `.-d . Type/Mfg r capachy • No. Compartments y Method __ of�D sa � PKG. TREATMENT PLT.❑ t � -. � �� f� I Distance to nearest: Well �� !`Foundation Property line f . • •� ` T�tal iangth/size [ LEACHIN ,I GNE No.'a Length of lines i . FILTER BED ii7 Distance to nearest: - We11 &L Foundation �Props M Una I SEEPAGE PITS it Depth f .Size r / Number _ _ • �. 1 SUMPS LI Distance to nearest: Weil_�L -,,roundation Pro l�ny Line �+ i ' i j DISPOSAL POfSDS. ❑ " l I hereby certify that 1 have prepared this application and that the work Wit be dobe in accordance with San Joaquin county ordine,,'- 6 j to laws, and rules and regulations of the San Joaquin Local Healml District. \, '"l4.,. Home owner ar licensed agent's signature certifies ths,fdiowing: "I certify that in the pe ormanca of the work for which this permit is issued,I shall not employ any person insuch manner as to become subject to workman's compensation laws of Cali hial"Cpioy persons hiring or m workmaacfmg n's an' ompansa- certifiesthe fo8o 'ng:,-i certify thanature t in the penormancet f the work for which this permit rs issued, .r tion Is, of C o nia.'• �- The app"a r all uired inspections. Complete drawing on rev side. 1 J i Signed X Title: I l ! OR DEPARTMENT USE ONLY Application Accepted by i Date Areal' ✓/ _..__ Date " Final Inspection by Date Pb or Grout Inspection by _ gg:� •�^�• •" 1 Additional Comments: . ❑ StL 46&6761 ❑ Lodi 3a9-3,\6'11 ••.1❑ Manters 623.9104 i� ❑Tracy fL15-6385 Stk., CA 95201 ' Applicant�Return all copies to: Environmental Heettls`permt/Servtc� 1&-E. Hazelton Ave., P.O. Box 2009, ..•�J + ' : I + FEE AMOUNT DUE AMOUNT REMITTED RECEIVED 6t' ;DATE, I ES a , dv Q PERMIT'NO. INFO `� �jEH14-21 isEV.1/N51 'EH 1448 ''� r