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I APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 I ' PERMIT EXPIRES 1YEAR FROM DATE ISSUED (Complete in Triplicate) ©o S_25V-Sfi Application is hereby made to the San County 04dinalnce No.549 for sewage or permit construct and/or Health District for a JoaNo. 1862 forwelilpump and the R l s and fl gulations application of the SanJoaquin made in compliance with San Joaq N Local Health District.: `('�Z cro-4ie ` Cit Lot Size PM 4 Job Address t Phone i Address Owner's Name owner!'s ' Phon - �Q r License No Contract Address + NEW WELL ElWELL REPLACEMENT 1-1DESTRUCTION ❑ , TYPE OF WELL/PUMP: OTHER IJ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE s \ 4 w_ FOUNDATIONAGRICULTURE WELL--- OT.HER,WELL —..PlTSI_SUMP_S;� �.. �.�I INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ��- pia. of Well Casing • k ❑ Oen Bottom © Manteca Dia. of Well Excavation 1-1 Industrial p Specifications Type of Casing Ll Domestic/Private ❑ Gravel Pack C5 Tracy Type of Grout ---� F1 Other F1 Delta Depth of Grout Seal i'1 Public ,..Approx. Depth I l Eastern Surface Seal Installed by + I 1 Irrigation State Work Done Repair Work Done ❑ Type of Pump H.P. Material (top 50'1 ' Well Destruction ❑ Well Diameter Seaing r Depth filler Mate-rias (Below 50') i TYPE OF SEPTIC WORK: NEVV-INSTALL-ATION.I 1, REPAIR ADDITION_iA DESTRUCTION 1.) (Noseptic sysshit 200 m-permiit'ed-it public sewer isavailable Installation will serve: Residence Commercial_ Other Number o b droom Number of living units: ; IF Water table depth r� + Character of soil to a depth of 3'feet; r Type/Mfg' Capacity No. Compartmen ts SEPTIC TANK f � Method of Dis'p'osal PKG. TREATMENT PLT. ❑ r } - Line: t- L Foundation Property - Distance to nearest: Well_ b _ LEACHING LINE No. & Length of lines TQta1 length/'se _ `� I Fo6i dation Property Line FILTER.SED ❑ Distance to nearest:,, Well�� -�� j pv, Depth iSize '�� T - Ymber C� SEEPAGE PITS / `+ �, �-- ty Foundation�" 5� .- Property Line'__— �- � SUMPS �1 Distance to nearest: Well - - DISPOSAL PONDS ❑ -- [7 iI I hereby certify that l have prepared This applica[ion and th$f the work will be done in_accordance with Sa JoaquiiYcbuntyFardinances, state laws, an ! rules and regulations of the San Joaquin Local Health DFstrict., following: "I certify that in the performance of the work for which this permit is issued, I shat! not Home owner or licensed agent's signature certifies the employ any person in such manner as s to become subject to workman's compensatibnlaws of California.-" Contractor's hiring or sub-contracting signature certifies the following: certify that the performance of the work for-which this permit is issued,I shall employ persons subject to workman's compensa- tion laws of California." + The applicant t call for eq red inspections. Complete drawing- eq reversew�� O - '"�" �` Date: Signed X Title.' I FOR DEPARTMENT USE ONLY -f 7 Date Area l� 7- Inspect y Application Accepted by tet- fixate! f T r pit Inspection ay ► ate �� ' Final Inspection by sone) Comments: _ n I ❑ Stk 4, Com 1 El Lodi 369.3621 ❑ Manteca 823-7104 ❑ Tracy 635-6385 Applicant- Return all copies to: Environmental PermitlSenrices 1601 E'Haielton Ave., P.O. Box 2009, Stk., CA 95201 yCK RECEIVED BY DATE PERMIT NO. FEE AMOUNT DUE AMOUNT REMITTED CASH INFO --7 ♦.EH 13-24(REV.I�H sr A' EH 14-26