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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT .— 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone 12091 466-6781 x PERMIT EXPIRES TYEAR FROM DATE ISSUED F (Complete in Triplicate) Coun Application is hereby made to the San oagn Local Health District for a permit to construct and/or insta4l ryOrdinance No. 549 for sewage or No. 1862 for welupump and the Rules and Regulations of the San Joaquin the work herein described.This application is made in compliance with San Joaqu Local Health District. PM City Lot Size Job Address • �yE✓0 Phone Address Owner's Name t ! License No. �1-ate-Phone AIYI- 41_Address Contractor� -�� WELL REPLACEMENT ❑ DESTRUCTION ❑ [ TYPE,OF WELLIPUMP: NEW WELL,❑. q LATHER ❑ «---_-_ - "SYSTEM REP,41R°❑�-'~�i �- PUMPDISPOSAL FLQ. PROP. LINE t` ! SEWER LINES —_--- PITS/SUMPS v[, - DISTANCE TO NEAREST: SEPTIC TANK OTHER WELL k FOUNDATION AGRICULTURE WELL INTENDED USE! TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS CAT10N5 Dia. of Well Casing i Dia. of Well Excavation k ❑ Industrial 1 U Open Bottom ❑ Manteca �E Specifications D Tracy Type of Casing I L1 Domestic IPrivate'i ❑ Gravel Pack Type of Grout 11 Other Cl Delta Depth of Grout Seal R l'1 Public w. Surface Seal Installed by % �_Approx. Depth I 1 Eastern I I Irrigation 1',r , 4 H.P. State Work Done_ Repair Work Donef© Type of+Pump ° Sealing Material Itop 58'1 Well Destruction ❑ Well Diameter Filler Material (Below 50'1 Depth available within 200 feet.I i -TYPE OF SEPTIC WORK: NEW INSTALLATION I i flEP: IR7ADD1710N i ! DESTRUCTION INo septic system permitted if public sewer is '•: Other Installation will serve: "Residence` Commercial�i` t' Number of living units: Number of beroom s,y ___ - ,,�f Water table depth t' Character of soil to a depth of 3 feet: No. Compartments --� ❑ Type/Mfg Gapacity��-- SEPTIC TANK Mff Method of Disposal s r I PKG. TREATMENT PLT. ❑ *F,..,.,, " • Property Line Distance to nearest: Well Foundation + € Total lengthlsize LEACHING LINE ❑ No. Length of lines ❑ Distance to nearest: Well Foundation property Line _�_� ? FILTER BED ;� } ' r Y Size Numbers . SEEPAGE PITS t I I Depth r Property Line —�-- 'I }Foundation P rty SUMPS 0 Distance to nearest: Well Y a w -� C � ,�- r i Y DISPOSAL PONDS "❑ I hereby certify that f 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. that in t k work for Home owner or licensed ageennt's signature gas to some subject wok man'srtcompensation lify he awsofCalifornians Contractor slhiri g othis P sub contract ngermit is issued, is signature employ any person in such ersons subject to workman's compensa certifies the following:."I certify that in the performance of the work for which this permit is issued,l shall employ p 1 tion laws of California." � .. ' . f The applicant must call for II requi d inspections. Complete drawing on reverse side.. t Date: Title: Signed FOR DEPARTMENT USE ONLY _ � Data 5Area Application Accepted by Date i 3 pate Final It by ` Ir la Pit or Grout Inspection by r( C 1A 35 Qqj -z— W i Additional Comments: r El 823-7404 ❑ Tracy. 835-6385 ❑ Stk 466-6781 J ❑ Lodi 369-3U1 5tk., CA 95201 Applicant - Return all copies to: Environmental Health.PermWServices 1601 E. Hazelton Ave., P.O. Box 2009, . Y --RECEIVED 9Y- �' '-�`` DATE FEE —_ .r AMOUNT DUE- «» AMOUNT�REMITTED^ - ` INFO EH 1324IREV.t/n 51 + EH 14.26 - _