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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED " (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work Herein described.This application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for welt!pump and the Rules and Regulations of the San Joaquin Local Health District. City Lot Size PM Job Address '£. *• Phone •zw:tea,�'4.. "'Address F r owner's Name - Address License No. Phone f Contractor tWELL REPLAC7 El DESTRUCTION DESTRUCTION ❑ r TYPE OF WELLIPUMP:. NEW WELL.❑ OTHER ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ SEWER LINES DISPOSAL,F_Lp.— P-ROP,_ LINE DISTANCE TO-NEAREST: SEPTIC TANK WELL OTHER PITS/SUMPS t �J FOUNDATION AGRICULTURE WELL it '{ i v'l INTENDED USE TYPE OF WELL PROBLEM AREA., CONSTRUCTION SPECIFICATIONS f]ia..of.'Well Casing ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of WeI�ExcTavaton e t v "Specifications Type of Casing ❑ Domestic I Private ❑ Gravel Pack El Tracy 1 4 T !p , Type of,Grout — l"7 Public [-I Other ❑ Delta Depth of Grout Seal ---' # 11 Irrigation —Approx. Depth i I Eastern 1 ` �r�face �aI installed by r l H.P.f State Work Done_ h i Repair Work Done_ L7 Type of Pump \ Sealing-Material [top 50') , l Well Destruction) C! Well Diameter _ / F,; Depth Filler Material (below 50'} t TYPE OF SEPTIC WORK: NEW INSTALLATION 1-1 EPAII /ADDITION I I DESTRUCTION l ],(No seti systemhin fr fitted if public,sewer is Installation will serve: Residence'� CommerciBlS-°_� )her available) �, Number of living units:. • Number of bedrooms — i III g1l f 1 Water table depth Character of soil to all. of 3 feet: ❑ Type/Mf r 1-Cepa .ty�� " No. Compartments r SEP_TIC.-IMViC g c s Method of Disposal p PKG. TREATMENT PLT.❑ Property Line Distance to nearest: r Well -- oundatiQrl ! g Tota! length/s ze� � LEACHING LINE ❑ No. & Length of lines Properly Line ° I FILTER BED ❑ Distance to nearest: Well Foundation :� Size Number E SEEPAGE PITS { I Depth , Property Line i SUMPS ILI Distance to nearest: C Well Foundation } I DISPOSAL PONDS ❑ \ r - 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 I rules and regulations of the San Joaquin Local Health DistucL Home owner or licensed agents signature certifies the following"I certify i�n the performance of the work for whichthis permit is issued, k shalt not employ any person in such manner as signature to become subject to workman's compensation law s of Ca-Tiornia." Contrace�sons{sub ect to woing or �kman�scompensa- I certifies the following: "I certify tff�t 911"1t�e perforrrlance of the work for which this permit is issued, I shall employ p I tion laws of California." The.applicant must call for all required inspections. Complete drawing on teverse side. I ` I Date: [ Title: I 3 Signed X t FOR DEPARTMENT USE ONLY 1 _ t l pate Area Application Accepted by T STT Date Final lnspecti by Date f Pit or Grout Inspection by �-- Additional Comments: ❑ 5tk 466 6781 ,� ❑ Lodi ti369-3621 �',� ❑ Manteca 823-7164,,,�,, rTracy 8356385 ,�s t. ,a ..:x. Applicant - Return all copies to:`Ervironmental Health permit/Services 1fi0L'E. Hazelton Ave., P.O.-Bo x ; Stk..., CA 95201 1'n A FEE AMOUNT DUE AMOUNT REMITTED >^CK 4'`RECEIVED BY DATE PERMIT NO. AS R S. 4 INFO EH 13-24(REV.I/n 5) - - EH 14-26