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APPLICATION FOR PERMIT - 6� SAN JOAaU1N'LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA V L� Telephone (209) 466-6781 U`V 4 �g�7 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 1 VEALJI, �� f �,. 3, (Complete in Triplicate) �L . onstruct and Application is hereby made to the San J,Joaquin Cooaquin Local unty O dinancee No-Districtalth 549 for sewage#o-r-rNo. 1862 for wellt pump and he Rules and ll th, e work rReguiat�� 'i made in compliance with San • , i lie U-e1,V, �� Local Health District.; f C�/ T[:F►�l b PM .� �� .y � Lot Size ! C! V e City Job Address ! q7 �- Phone C(S.SQ Q Address 0 TW Owner's Name l /� Y�5 Address 1 ►"'� "nse No. Y Phone Contractor WELL NEW WELL € REPLACEMENT ❑ DESTRUCTION OTHER El OF WELLlPUMP: SYSTEM REPAIR ❑ 'i PUMP INSTALLATION ❑ DISPOSAL FLD.-IIIIIIPROP. LINE "SEWER LINES -- 1 I DISTANCE,,TO NEAREST: SEPTIC TANK OTHER WELL—,�— PITSlSLIMPS FOUNDATION �--AGRICULTURE WELL -" i� INTENDED USE TYPE OF WELL PROBL� EM AREA CONSTRUCTION SPECIFICATIONS pia. of Well Casing ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Specifications ❑ Indust'rial Tracy Type of Casing Domestic/Private '�(Gravel Pack l �_ � Type of Gro t ❑ Other ❑ Delta Depth of Grout Seal ❑ Public Surface Seal Installed by J �pprox. Depth ❑ Eastern State Work Done ❑ irrigation H P Repair}Work Done ❑ Type of Pump r•- 1 Sealing Material flop 50'1 Well jOestruction ❑ Well Diameter �� Filler Material (Below 501 Depth ermitted if public sewer is available within 200 feet.) TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIRlADDITION ❑ DESTRUCTION ❑ (No septic system p In stalla - . erne: Residence Commercial Other Number of bedrooms Water table depth Number of living units: - Character of soil to a depth of 3 CapacitY— No. Compartments .SEPTIC TANK ID TypelMfg Method of Disposal rPKG. TREATMENT PLT. ❑ Foundation Property Line Distance to nearest: Well 1 I length/size LEACHING LINE E-1 No. & Length of lines r Line ❑ Distance to nearest: Well Foundation FILTER BED ❑ Depth Size Number SEEPAGE PITS Foundation� Property Line SUMPS CJ Distance to nearest: Well te laws, an -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, sta ,. I rules and regulations of the San Joaquin Local Health District.g that in the performance of the work for which this permit is issued, I signature shall not Home owner or licensed agent's signature certifies the ft to workman's I certify of employ any person in such manner as to n the ec performanceof the work foswhich compensation tpermkv+s issued,fl shall employ persons ksubject t ring or bworkman''s9ompensa certifies the following:"I certify that i PB i tion laws of California."/ lica m t call for all required ' pections. Com late drawing on r verse si e. The app' Date: Title: Signed - OR pEPA MENT USE ONLY (�5 Area Date Application Accepted byate ��.QQ�� ;� r �- Final Inspection by r Pit c Grout I spection b t 1 i Additional Comments: ❑ Lodi 369 ❑ Manteca 823-7104 ❑ Tracy 835-6385 95201 ❑ Stk 466-6781 Applicant Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P:O. Box 2009, Stk., CA C RECEIVED BY DATE PERMIT`NO. FEE AMOUNT DUE AMOUNT REMITTED y�j INFO .---- i +,EH 13-24(RSV.1/8 5)