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App►-►�p�►oN�oR TH DIS'�RIG� ' ' �l SAN ,10AaUiN LOCA CAL HEAL , Z 'VE., STOCKTON•. 1 1601 E. H AZEL T ON A 678'1 Telephone 12091 PATE 1S5UED YEAR FROM PERM{T EXPIRE$ licatel This apPl;cation is (Complete in Trip or and the Rules and Regulations of the San Joaqu'n Local Health District for a permit n construct orweIt/por p an the work herein descrl 862 APPlicatian is heiebV made to the San Joaqu'Ordinance No.549 for sewage or N made in compliance with San Joaquin County PM Local Health District. Lot Size L,/ 7, L city Job Address ` � �8 Sr+�►ERrabt? 111M1- f26- 0-31 phone 4 Som Address Owner's Name Lf/�_g �phone 2+ w �� License No. _ Address DESTRUCTION Cl Contractor WELL REPLACEMENT ❑ TYPE OF WELL/PUMP: NEW WELL ❑ OTHER >(MOA)�Tl?��'EJ SYSTEM REPAIR F-1pump INSTALLATION ❑ DISPOSAL FLO. PROP. LINE DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES �— — p1T5lSUMPS FOUNDATION AGRICULTURE WELL OTHER WELL INTENDED USE TYPE OF WELL PROBLEM AREA, CONSTRUCTION SPECIFICATION 5 rj Industrial �� Dti Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Type of Casin .3 D QVC Specifications ❑ Domestic/Private Ll Gravel Pack r ❑ Tracy YP Casing.3 SO� Type of Grout C1 Public ❑ Other ❑ Delta Depth of Grout Seal . Irrigation ----Approx. Depth i ] Eastern Surface Seal Installed by N A .�DGS Repair Work Done fl Type of Pump H,P. State Work Done , Well Destruction ❑ Well Diameter _= Sealing Material itop 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/ADDITION ❑ DESTRUCTION ❑ INo septic system permitted if public sewer is available within 200 feet.) installation will serve: Residence__ Commercial— Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK - 0 Type/Mfg _ Capacity No. Compartments PKG. TREATMENT PLT.•❑ Method of Disposal Distance to nearest: Wel Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED L) Distance to nearest: Well oundation Property Line SEEPAGE PITS ❑ Depth Si Number SUMPS Cl Distance to nearest: Well Foundation DISPOSAL PONDS ❑ Property Line I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued,1 shall not employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work for which this tion laws of California." permit is issued, !steall employ persons subject to workman's compensa- i The applicant m t all r all eq s Pections, Complete drawing an r arse side. Signed X Tice: • r .� Date: 12- R F DEPARTMENT USE ONLY --------- Application Accepted by � , Pit or Grout Ins Date Inspection by _ Area Date�� Fina! Ins Additional Comments; Pection by ❑ Stk 466-6781 Date L7 Lodig 3fi21 Applicant - Return all copies to: Environmental Health Permit/Seerviceanteca s41601 E❑Hazehon Tracy {Ave., P.O. Bo 638,5 r FEE x 2009, Stk., CA 95201 INFO AMOUNT DUE 'AMOUNT-RFMITTED CK t r3 N fA CASH RECPVED By DATE PERMl7"NO. w J.