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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1'YEAR FROM DATE ISSUED (Complete in Triplicate) work /or install the Application is hereby made to the San Joaquin Local H No.549 for sewage or cation is th District for a permit 1862 forcwe lapump and the Rules and IR Regula of the Sa. This n J aquin p compliance with San Joaquin County ordinance made in comp � Local Health District. , Cit tot Size 2 0 �M q2�Job Address PhoneAddress -� Owner`s Name __ .. �- •j% / 4 7 Phone j License No ` Contractor Address WEL PLACEMENT ❑ DESTRUCTION ❑ ` TYPE OF WELL/PUMP: NEW WELL ❑ OTHER ❑ r SYSTEM REPAIR ❑ PROP. UNE A PUMP INSTALLATION ❑ DISPOSAL FLD. 'k g SE ER L ES '_�— s PITS/SUMPS DISTANCE TO NEAREST: SEPTIC TANK _�— OTHER WELL " r FOUNDATION ��-- AG C TUBE WELL �- t INTENDED USE � TYPE OF WELL PROBLEM A CONSTRUCTION SPECIFICATION Dia. of Well Casing, Dia. of Well Excavation .. ❑ Industrial --t-�-❑ Open Bottom ❑ Mantec Specifications\ ❑ Tracy Type of Casing +�; - ❑ Domestic/Private 171 Gravel Pack Depth of Grout Seal Type o1 Grout n Other Cl Del I'1 Public �.� ,Surface Seal installed by Approx. Depth t I stern + . I 1 Irrigation •�,�s State Work Done " Repair Work Done ❑ Type of Pump H.P 5eali g Materia!<hop 50'I ,. �} t Well Destruction ❑ " Well Diameter Piper Material (Belo piiiii Depth r k available within 200 fee" TYPE OF SEPTIC WORK: NEW INSTAL TION I.1 REPAIRIADDI PION t. i DESTRUCTION l I (No septic system permitted if public sewer is 1 r Other f Installation will serve: Residence Commercial_ , Number of living units: Number of bedrooms—2— Water table depth ' ` r Character of soil to a depth of 3 feet: )� ,��!,,� � Capacity No. Compartments SEPTIC TANK ❑ Type/Mfg > E =� �: 'Method of Disposal ' PKG. TREATMENT PLT. ❑ Prope"rty.Line + �� Distance to nearest: Well L� —♦Foundation41 I f I T'tallengthGsize (n ( LEACHING LINE Cl No. &9 Length of lines el_�(� Foundation Property Line " FILTER BED ❑ Distance to nearest: _ t r R : iSize— SEEPAGE r!° l r �� Number 1 1 Depth ' !,N Size,� SEEPAGE PITS d Foundation`�r Property Line t ---—SUMPS L� "DistanGe'to n a st: ' Well�klr1 _ ; DISPOSAL PONDS ❑ I hereby certify that I have prepared this applidation and that the work will be done in accordance with San Joaquin county ordinances, state laws, an rules and-regulations of the San Joaquin Local Health Di tict. _' r jfy. in the ! not Home owner or licenseucl9�nne as fosignature cb ife subject Ito wlorkr"an'srtcampensation laws of Californiah" Contractor's gr or sub-contracting lsignature employ any person ersons subject to workman's compensa r certifies the following:'"{certify that in the perlot�afe of the work for which this permit is issued, I shall employ p 1 tion laws of California." The applicant m t cal for all ired ins tions. Cori drawing on reverse side. ! Title: Date: V Signed X ` FOR DEPARTMENT USE ONLY 12— Date Date Area Eh ` Application Accepted by � Final Inspection by Date Gt/ ! Date�-- Pit or Grout Inspection by Additional Comments: 0'l El Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca ervi 04 D Tracy 835-6385 nvironmental Health Permit/SServices 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 Applicant- Return all copies to: E CK RECEIVED 9Y DATE ERFEE AMOUNT DUE AMOUNT REMITTED CASH INFOGr/� f' RS!EH 13-24(REV.r/H 5) !a "r �.�,�..�. •� EH 14-28 - s