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APPLICATION,FOR•PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT PERMIT NO. 1601 E. HAZELTON AVE., STOCKTON„CA., Telephone (209) 466-6781 " DATE ISSUED PERMIT EXPIRES 1 YEAR FROM DATE ISSUED` (Complete in Triplicate) e work rein Application is hereby made to the SSa Jo qu-in Local with Districtuin fora permit inance�NostS49tfordsewage orlNo...186?h for ewell Pump t described. This application is -, � ,,and the Rules and Regulations of thelSan Joaq in Loc 1 Health District. Job Address jld �eg �4/ Subdivision Name' Phone Owner's Name S'�ErU_�a��n'�^'`"' Address ..+ License No, a�-- Phone Contractor's Name�v� -- DESTRUCTION TYPE Of WELL/PUMP WORK: _NEW WELL uWELL REPLACEMENT DESTRUCTION TYPE �»--.--•-- �^^-""". �' 1 U OTHER PUMP INSTALLATION CJ SYSTEM REPAIR j SEWER LINES DISPOSALIFLD. PROP. LINE i i b DISTANCE TO NEAREST: SEPTIC TANK {_ OTHER WELL ! PITS%S17fAP '��? 3 FOUNDATION _AGRICULTURE WELL• 1 i ----- k s CONSTRUCTION SPECIFiICATIONS • INTENDED US£s 7YP£ OF WELL PROBLEM AREA pia. f Well Excavation i �. IndustrlaT�• i []Open Bottom ❑ ( ( �� o Manteca Dia. of well Casing F-1 Tracy Domestic/Pri'vate Q Gravel Pack E] 'Sa ; i t S 0 Public 1 ClOtheri ED ml to OType of Casing V Irrigation s Approx. ❑Eastern Specifications Depth peQthyofYGroutSeal. cathodic Protection , Z t [�Geophysical ; �iType of Grout I i , Other Surface Seal Installed by� t. i HipState Work Done Repair Work Done 0 Type•of Pump H 3 — Well Destruction 0 Well Diameter �i;Sealing Material (top 50'). : Depth a Filler Material (Below 50') , permitted ifi_pab+ic-sewerti•s-_^: T—TYPE OF SEPTIC WOkK: NEW INSTALLATION 1 -REPAIR/AODIT�I available within 200 feet.} Installation will servetN : Residence Commercial _ Other / + L L j e t Number of bedrboms Lot size l b. ; ''' �-G C-. Number of living units: "- Water table depth, Character of soil to a depth of3 feet: Capacity a0o) Compartments I{ SEPTIC TANK I M Type/Mfg ethod of Disposal PKG. TREATMENT PLT. Type/Mfg Capacity MSSP { c^ roper-': line Distance nearest: Well Foundation'_ �Jr r SEWAGE SYSTEM r DESTRUCTION i I J9'Total, length/size t LEACHING LINE No. & Leiigth of tines � `I '_' ' Property;Line { FILTER BED Distance to nearest: Well _ Foundation' I � • Number,,. ....._.4 k f ....�- SEEPAGE PITS [] .D�Pth - Size SUMPS l-1 ,' Distance to nearest: Well ' Foundation Property Line i DISPOSAL PONDS ❑ I i I hereby certify chat 11haderulesaand regulationsaof then SarihJoaquinwLocalrk iHeall lthdDistrone Rctccordance with San Joaquin county ordinances, Home owner or licensed agent's signature Certifies the following: t certify that in the performance of the,work for which this permitis shall not t emactir.gnsignaton i such iesnnez following. certify that rinathe cperformance Ofwthe fwork�fornwhich Contra g ersons re cert to workman's compensation laws of California." k this permit is issued, I shall employ'persons The applicant must cal re inspections- Complete drawing on reverse side. Date: Title: Signed X c y i FOR DEPARTMENT USE ONLY Stk 466-6781 ( Area Application Accepted by ; L1 Lodi 369-3621' AdditionaliComments: Manteca 823-7104 Date L�� ❑ ' Pit or Grout Inspection by *ent� Date �/Z�` -Gt'C� Tracy 835-6385 Final Inspection by Applicant - Return all copies to:• Envh Permit/Services 1601 E. Hazelton Ave., P.O. Sox 2009, St k., CA 95201 e - 3 RECEIVED BY DATE PERMIT NO, FEE BASE ;AMOUNT DUE AMOUNT REMITTED 5DO EHT23-24 R6V.A10/82 �• i 14-26 '