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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone 12091 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) is A lication is hereby made to the San Joaquin Local Health Districtfor sewa permit e or No. 1862 for we I/dpump atall the work herein describe ,nd the Rules and Regulations of tlhe Sanapplication Joaquin PP made in compliance with San Joaquin County Ordinance No. 9 Local Health District. �y f 2 '1 �3 = ' �+ ( (Z00% City J A _00 Lot Size PM Job Address X23• � '�3 {.Ll l 11 l�►/�:S � ' � Address _ j f©y rS. �c•V 0 rti Phone Owner's Name 2e/3ga� Phone��- -7rrM C'-F�ifC+f`ve ~y Address �Sa u i r4s,aJ sem License No. .- Contractor DESTRUCTION ❑ ' TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ PUMP INSTALLATION ❑ tSYSTEM REPAIR ❑ E OTHER ❑` SEWER LINES a, } DISPOSAL FLD. PROP. LINE DISTANCE TO NEAREST: SEPTIC TANK i FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS ft ` INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Da. of Well Casing ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation - Specifications I ❑ Domestic/Ptivate ❑ Gravel Pack ❑ Tracy Type of Casing i Depth of Grout Seal Type of Grout - ❑ Public ❑ Other ❑ Delta - - I I Irrigation —.Approx. Depth I I Eastern Surface Seal Installed by H P ' { State Work Done �� f Repair Work Done ❑ Type of Pump t Well Destruction ❑ Well Diameter Sealing Material(top 50'1 # J Depth Filler Material IBelow•5D'l� + TYPE OF SEPTIC WORK: NEW INSTALL TION I REPAIR/ADDITION l I DESTRUCTION I I availableNo septic wthin 200 feet.) if public sewer is n 4 Installation will serve: Residence— Commercial Other I Number of living units: i Number of brooms AAy 1 Water table depth ' Character of soil to a depth of 3 feet: No. Compartments SEPTIC TANK ❑ Type/Mfg V� �" �'Capacity t ' {� Method of Disposal PKG. TREATMENT PLT. ❑ Foundation j J Property Line $put Distance to nearest: Well r LEACHING LINE No. 8s Length of lines ' '"- O X16 notal leng h/size rV Property FILTER BED L3 Distance Distance to nearest: Well Foundation P y Line x t Number Size SEEPAGE PITS I I Depth { Q property Line SUMPS LK_Distance to nearest: Well 11 Foundation a. DISPOSAL PONDS ❑ - - i ' 4 I hereby certify that I have prepared this application and that the-work-will-be-clone-in,accordance with.San-yoagwn countyordin�ances, state laws, and rules and regulations of the San Joaquin Local Health District. Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the,work for which this permit is iseLed, I shall not employ any person in such manner as to become subject to workman's compensation laws,of California."Contractor's hiring or sub-contracting signature certifies the persofollon I certify that in th performance of the work for which this permit is issuad,1l shall employ-persons'subject to workman"s compensa- tion laws of California." The applicant call for a4 required spections. Complete drawing on reverse side. ' Date: Signed X "''► Titles- ---— , 1 FOR DEPARTMENT USE ONLY �� 3- fate'= Area t Application Accepted by G t ' fDate O - Pit 4rout Inspection by Date Final Inspection-by Addi bnal Comments: ❑ 5tk 466-6781 ❑ Lodi 369-3621 ❑ anteca 823-7104 ❑ Tracy 835-6385 -1601-E-Hazelton-Ave:-P:O-8ox 2009;StkGA 95201- Applicant Return allrcopies..to:-Environmental-Health.P.ermit/•Services E GK RECEIVED BY DATE PERMIT-NO. r FEE AMOUNT,D!J1 ,AMOUN EMITTED H INFO + EH 13- EH iiH51 EH 14-26