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APPLICATION FOR PERMIT s SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL 1 ON AVE., STOCKTON, CA -- Telephone (299) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE 1SSUED , 3 rti q (Complete in Triplicate) and the Rules and Regulations of the San Joaquin PP q Ocation is hereby made to the San Joaquin Lo cal Health No.No.District549 far sewage or Noa 1862 for welVpumpstaU the work herein described.This application is made in compliance with San Joaquin County Ordinancef.4 . :�. � . Local Health District. Lot Size PM k. Job Address t� '� +V i i� City d Address �G- L: Phone 3 " Owner's Name J0 License No_ done ContractorAddress, REPLACEMENT ❑ DESTRUCTIQN ❑ WELL TYPE OF WELL/PUMP: NEW WELL ❑ OTHER ❑ SYSTEM REPAIR ❑ PROP. LINE PUMP INSTALLATION D DISPOSAL FLD. 1 I SEPTIC TANK l- SEWER LINES �� PITSISUMPS . DISTANCE TO AGRICULTURE WELL OTHER WELL 3 - FO ON �� EM AREA CONSTRUCTION SPECIFICATIONS INTENDED USE TYPE OF WELL Dia. of Well Casing 1 Bottom ❑ Manteca a. of Wap Excavation ❑ Industrial ❑ Open TSpecincations Type of ❑ Gravel Pack [I Tracy Type of Grout i ❑ Domestic/Private C1 Delta Depth of Grout Seal L] Public [-I Other Surface Seat/ installed by --Approx. Depth ❑ Eastern k j . ❑ irrigation State Work Done Type of Pump _ H.P. *, 'E w Repair Work Done C] .»Sealing-Material-000-50'7 -» Well Destruction ❑ Well Diameter-- Filler Material {Below 50'? Depth av liable within 200 feet.? TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIRIADDITION ❑ DESTRUCTIO 0 septic system Permitted if public sewer is Installation will serve: Residence—" Commercial Other I Number of bedrooms" ` ' I Water table depth Number of living units: (� f I1! i Character of soil to a depth of 3 feet: Capacity-- No. Compartments SEPTIC TANK ;❑ Type/Mfg Method of Disposal i f, �- PKG:"TREATMENT PLT.❑ Foundation Property Line 1 Distance to nearest: Well E + _ . �.•••.--.--c -•- """'Tvtallengthlsize 'w LEACHING LINE _ ❑ ..No:'&'Length of likes Foundation a Property Line FILTER BED > ,. L] Distance to nearest: ..Well F 1 , "^• c Number " f ❑"Depth- ... r .. Size . . .. -_P i Foundation SEEPAGE PITS WJ �'" ~Property.Line SUMPS .... ❑ Distance to nearest: Well R .. t DISPOSAL PONDS ❑ -,W that the work will be done in accordancee v+rrth San Joaquin county ordinances, state laws, and 1 hereby certify that'l have prepared this application and rules and regulations of the San Joaquin Local Health District. work Home owner or licensed agent's signature certifies the following: compensation law"I certify that in the s of California." Contracto�slha ng othis r sub-contractingrmit is issued, lsignlature ' person in such manner as to become subject to Workman's employ any 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 compen - tion laws of California." ` The applicant must call for all required inspections. Complete drawing on reverse side. Date: r 'h?azidam- Title: i 1/Signed 1J� FOR DEPARTM T USE ONLY q Date f Area Application Accepted by Date �Z ? -� pate Final Inspection by Pit or Grout Inspection by • Additional Comments: ❑ Manteca 823-7104 ❑Tracy 835 6385 k ❑ Stk 466-6781 ❑ Lodi 369-3621 ` Applicant Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED 8Y DATE PERMIT'NO. INFO q w 1 +SEH 13-241REV.5051 EH 14-28