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APPLiCATIO FOR PERMIT SAN JOAQUIN LOCAL 11EALIH DISTRICT PERMIT NO. 1601 E. MAZELTON AVE., STOCKTON, CA 1 Telephone (209) 466-6781 DATE iSSL'EO PERMIT EXPIRES I YEAR FROM DATE ISSUED (Complete in Triplicate) riiV.. to l the 'shmarein San9Joaquin Local Health District CountyOrncecNo. 549tor fdsewagelor sorlNo. 1862rfor cooewell/Pump de Application is hereby made 1 described. This application and the Rules and Regulations of Lha/ San in Lo, cal SubdivisionHealth District, Name 04 Job Address eA � qv� , �` ,rs � —Phone — Address _�r �+-- Phone C4 owner's Name License No. Contractor's Name _At&_/_11fJlA�� WELL REPLACEMENT C3 DESTRUCTION❑ t. �' j TYPE OF WELL/PUMP WORK: NEW WELL ❑ SYSTEM REPAIR OTHER PUMP 1NSTALLATiON ❑ DISPOSAL FLO. _•PROP• LINE _ •SEWER LINES' PITSlSUMPS DISTANCE T, NEARES?: SEPTIC TANK ._ `� OTHER WELL FOUNDATION __�_- AGRICULTURE WILL ___ _ — .?R INT a"COfi5TRUCTION SPECIFICATIONS _ INTEN_DED USE TY?E OF WELL PROBE_ E?REA qManteca Dia. of Well Excavation _— 1 industrial_ Lj•Open,Bottom . Dia. of Well Casing Gravel- Domestic/Private -� Pack Tracy � •: (�Other Delta Type of Casing Public Approx.. Eastern Specifications Irrigation Death Depth'of Grout Seal Cathodic Protection Type of Grout U Geophysical Surface Seal Installed by J lJ Other Repair work Done [] Type of Pum MP ��H P State Work Cone � Sealing Material (top 50') Weil Destruction ❑ Well Diameter �� Filler Material (900w 50') Depth tge pit permitted if public sewer 1s kEPA1R/ADDITI04 (No septic ank or seepaavailable within 200 feet.) TYPE OF SEPTIC WORT:: NEW INSTALLATION U wr Other Installation will serve: Commercial ,'�Residence Lot size T Number of living units: Number of bedrooms �� Water table depth �-- �- d L Character of soil to a depth of 3 feet: nj_ No. Compartments Capacity SEPTIC TANK . LI Type/Mfg Capacity �— Method of Disposal i PKG. TREATMENT PLT. Q Type/Mfg nee to nearest: well — Property Line•��_ Foundation �- — C SEWAGE SYSTEM C3 Distar— O DESTRUCTION i Total length/Size LEACHING LINE No. & Length of lines Z-79---T — _ Property Line Foundation FILTER BED C3 . Distance to nearest: Well _I _ Number Size SEEPAGE PITS Depth Foundation Property Line SUMPS LI Distance to nearest: well ,�-- i DISPOSAL PONDS I hereby certify that I have prepared this application and that the work will ne done in accordance with Sar. Joaquin county s T certify that in the per of the work for which this ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. Home owner or licensed agent's signature certifies the allowing: ' that km the performance of the work for which permit is issued, 1 shalt not employ any person in such manner as to become subject to workman�compensation laws of California. ' Contractor's hiring or sub-contracting signature certifies the following: at-certify this permit i5 issued, I shall employ Persons subject to workman' onareversewside yalifornia." applicant must call for all required inspections. Coma Date: The app L Title: Signed X DEPARTMENT USE ONLY Area F�Stk 466-6781 l —. _ 1 Application Accepted by j,,,�,, k,.:,� Lodi 36,9-36Z1 Additional Comments: S_ f �—�� Manteca B23-710a Date 835-6385 Pit or Grout inspection Date .s' 1 1 [-{ Tracy CA 95201 Final Inspection by 2009, — -- =DATE- Return all copies to; Environmental Health Permit/Services t6 1 E. Hazelton Ave., P.O. Box PERMIT N0.' RECEIVED 6Y FEE BASE AMOUNT DUE AMOUP+T REMITTED C 1 I INFO — — I _3 10/82 500 Ei: 13-24 REV. 10/82 / - SCC CrLKw/�l oN �Q o 14-26