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NEAPPLICATION FOR PERMIT DH- ECE1 DISTRICT LOCAL HEALTH SAN JOAaUIN R0� 1601 E. HAZEL T ON AVE., STOCKTON, CA .� L 10 Telephone (209) 466-6781 '.NV IRCMMENTAL HEALTH PERMIT EXPIRES 1'YEAR FROM DATE ISSUED °� PERMIT/SERV'CES (Complete in Triplicate) cation is all the work Application is hereby made to the County ordinance lHealth District for a No. 549 for sewage or permit No. 1862 for well/dpumlp and the Rules and herein Regulationds of the Sanis Joaquin made n compliance with San JoaquinN Local Health District. City Lat Size PM Job Address Phone Address Owner's Name s .3 6";L_ Phon Contractor - Addres 3n License N TYPE OF WELL/PUMP: NEW WELL Ll WELL REPLACEMENT ❑ DESTRUCTION ❑ SYSTEM REPAIR 4 Y OTHER ❑ PUMP INSTALLATION ❑ PROP. LINE _,SEWER LINES .. DISPOSAL FLD. _. ._,-..._. AGRICULTURE WELL OTHER WELL— FOUNDATION ELL ' - MT57SUMPS;�"� DISTANCE TO NEAREST: SEPTIC TANK FOUND_ATt01V Y -' INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS pia. of Well Casing ❑ Open Bottom ❑ Manteca Dia. of Well Excavation ❑ Industrial Specifications Type r �mestic/Private Ll Gravel Pack ❑ Tracy YP of Casing Type of Grout r I` Public I n Other n Delta Depth of Grout Seal ..Ax. Depth l l Eastern / Surface Seal installed by - I Irrigation —.,Approx. H P State Worl< Done nQ Repair Work Done Type of Pump Sealing Material (toP 50'1 Well destruction ❑ Wel! Diameter , _ LJ� Depth Filler Material (Below 50'1 No l TYPE OF SEPTIC WORK: NEW INSTALLATIdN l 1 REPAIR/ADDITION l 1 DESTRUCTION I I availableseptic within 200 feet.) if public sewer is ' Installation will serve: Residence_ Commercial_ Other',_} �' k Number of living units: Number of bedrooms Water table depth Character of soil to a depth of 3 feet: Capacity No. Compartments f SEPTIC TANK ❑ Type/Mfg Method of Disposal I PKGLLTREATMENT PLT. ❑ , Distance to neatest: Well Foundation .. Property Line 'r r Total Iengthlsize LEACHING LINE ❑ No. & Length of lines Property Line 1 FILTER TIED ❑ Distance to nearest: Well Foundation P Y I Depth Size Number SEEPAGE PITS Property Lute. -- .—SUMPS. HCl ;,,Distance to nearest: �-,Well,- - =Foundation 4 - �^*� �4 I DISPOSAL PONDS ❑ I hereby certify that I 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 Di§trict. I ture certifies the following: certify that in the performance of the work for which this permit is issued, 1 shall not Home owner or licensed agent's signa employ any person in such manner as to became subject to workman's compensation laws of California." Contractor's hiring of sub-contracting signature certifies the following: "I certify that in 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 mu c I or all required inspections. Complete drawing on reverse side. v iTitle: Date: Signed X J�OR �RTM�ENTSE ONLY O Area Date Application Accepted by Date Final Inspection by Date Pit or Grout Inspection by 6 r Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 [D Manteca 823-7104 L3 Tracy 835 6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazalton Ave., P.O. Box 2009, Stk., CA 95201 FEE - CK RECEIVED 8Y DATE PERMIT NO. AMOUNT DUE AMOUNT REMITTED CASH INFO , `{ b +.EH13-24(REV. x5) EH 14-26