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APPLICATION FOR,PERMIT SAN JOAQUIN LOCALMEALTH DISTRICT 1601 E. HAZEL—ION AVE., STOCKTON, CA Telephone 12091 466-6781 . I ,i. ... .. , .r PERMIT EXPIRES 1 YEAR FROM. DATE ISSUED ,. . �; •: �...,M (Complete in Triplicate) application is e or No. con for well/PUMP and the Rules and Regulations of the San Joaquin Application is hereby made to the San Joanui"Ord°.mance No.District549 for sewage permit to construct andlor install the work herein described:This made in compliance with San Joaquin County Local Health gf]istrict.- ,, k. . :4I PM ` City Lot Size l- :4 '-, j l Job Address "`.':, ..'a -- - . •�f �.- Phone: Address a 4 Owner's Name '� f '' (� R*,,� `�� + Phone cense No. j Contractor's Name DESTRUCTION ❑ NEW WELL ❑ * WELL REPLACEMENT ❑- � tOTHER ❑ TYPE OF WELL/PUMP: SYSTEM REPAIR ❑ PUMP INSTALLATION ❑ DISPOSAL FLD. PROP. LINE r ''ti SEWER LINES —�� PITSISUMPS DISTANCE TO NEAREST: SEPTIC TANK. AGRICULTURE WELL OTHER WELL� t FOUNDATION �� ITYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS pia. of Well Casing INTENDED USE ❑ Manteca Dia. of Well Excavation El Industrial . a. Q Open Bottom Type of Casing Specifications ❑ Gravel Pack El Tracy y�Type of Grout Q Domestic/Private pepth of-Grout.Seal _. . .. -. ❑ Other .,..�._-❑-De1ta�..,..r,..,-- ❑ Public Surface Seal Installed by ❑ Irrigation --Approx. Depth ❑ Eastern State Work Done Type of Pump H.P. Repair Work Done ❑ Sealing Material (top 50') Diamete�Y" � Material Bel w 50`). Well Destruction f"[3—Well �. t Depth tic system permitted if public sewer is f available within 200feet.) TYPE OF SEPTIC WORK: NEW INSTAL ON ❑ REPAIR/ DDITION DESTRUCTION ❑ o sap F Other l� Commercial I Installation will serve: Residence ^ Number of bedrooms Water table depth ( d � Number of living units: � O Character of'sbit to a depth-bf 3 feet: Capacityl— No. Compartments I SEPTIC TANK ElType/Mfg ` A-» - � �"'-Methadof Disposal r PKG. TREATMENT PLT. ❑ Foundation Property Line. — I Distance to nearest: Well t Total Iength/size LEACHING LINE ❑ No�& Length of lines Foundation Property Line ❑ Distance•to nearest: Well FILTER BED i .,k •' .l�: �t Number ❑ Depth Size Line�- 1 SEEPAGE PITS # , Foundation� Property ❑ Distance to nearest: Well SUMPS DISPOSAL PONDS ❑ --I-hereb ceGtify that I'have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and YJ.- rules and regulations of the San Joaquin Local Health District; g sub e subject to workman's compensation laws of Califf hi II employ perrsonslsubl crt t workman'scompensa l Home owner or licensed agent's signature certifies the followin I certify that in the performance ohehe Corky ct which this permit is issued, I s a no employ any person,n such manner as to beco I certifies the following: "I certify that in the performance f the waf rk� fo.which-h this permit is issued�s P � ~� a tion laws-of California-'-- -- drawing on rev side. The applicant m call all vire i s ctions. Com �-Date: Title: Signed FOR DEPARTMENT USE ONLY D a3a Date Area Application Accepted by Date Date Final Inspection by t Pit or Grout Inspection J Additional Comments: erm ❑ racy 835 6781 Lodi 369-3621-3621 ❑ s 823 7104 h Applicant- Return all copies to: Environmsntal Health pPermit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 Q Stk 466- 1 r CK RECEIVED BY DATE, PERMIT"NO. FEE AMOUNT DUE AMOUNT REMITTED CASH r. INFO ■/�,j�. �� I/I '7�Q' ra�aZO CH tz-za IREv.I0183l - _EH 1426