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APPLICATION FOR PERMIT SAN JOAQUIN'LOCAL HEALTH DISTRICT 1601 E. HAZE i ON AVE., STOCKTON, CA Telephone (209) 466-6781 y PERMIT EXPIRES TYEAR FROM DATE-ISSUED (Complete,in 'triplicate) work n described. This all the .Application is heiebyNmh de Sancation is oJoaqu the n County Ordinance No. 549 for sewage or uin Local Health District for a permit 1862 for we well/pump and the Rules and IR Regulations of he San l Joaquin •� made in compliance Local Health District. V e_9 City / ( ' )e Lot Size _ PM Job Address f r /��ac Ali 0 U�. Phone Owner's Name � /�� Address _��YJ7E ^ 85 _ I �1 �d s1-' 0. � 8�1 /''lark license No. S_ Phone Contractor e % �'7 Ad'dres NEW WELL - WELL REPLACEMENT El DESTRUCTION ❑ TYPE OF WELL/PUMP: SYSTEM REPAIR ❑ OTHER ❑� PUMP INSTALLATION,K a� PROP. LINE I'I DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES ` DISPOSAL FLD� ! EOUNDfATI f _Q GRI,CULI11.f3E_W.EJ L _..=O_T ELL- ,,•.—^ -ITS/SUMPS y INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Di of Well Casin ❑ Industrial ❑ Open Bottom Manteca Dia. of Well Excavat' n e�iS�J /) Pack ❑ Trac Type of Casing � Specifications F ravel Pa Y Private G ` Domestic/ Ty �e of Grouti/JiZ_��' — ['1 Public f`Other _ Z". O1.Deita� Depth of Gro ut.Sea1 4 d bylle I I Irrigation �_Approx. Depth i ('Eastern Surface Seal installed i ! Stat -W.o►k..0one l Repair Work Type,of Pump. , Well Qestruction ❑ Well Diameter Sealing Material atop 50'l --- well Material (Below 50'I - 2 l Depth - } TYPE OF SEPTIC WORK: -NEW INSTALLATION Il REPAIRIAUDtTION Il �OESTRUCTION l 1, avlailabletwthine2 Permitted if public sewer is I installation will serve: Residence Commercial_ Other 4 f Number of living units: Number of bedrooms - "�--•' _ t Water table epth c Character of soil to a depth of 3 feet: y No. Compact ents SEPTIC TANK ❑ Type/Mfg Capacity 5. i Method of D sposal• } PKG. TREATMENT PLT. C1r^ ;;r,_ l Distance to nearest: Well Foundation Property Line Total length/size _ LEACHING LINE ❑ No. lit Length of lines Property Line FILTER BED L1 Distance to nearest: Well Foundation I SEEPAGE PITS 11 Depth Size Number 1/SUMPS ' Cl Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin ca my ordinances, state laws, and f 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 whict this permit is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's h ring or sub-contracting signature j 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 E tion laws of!California." The applicant r t_cal for all requir ..ins tions. Complete drawing on reverse ide. a �-�+�+�-� / �a Y / a. i Title: 177 / ' t3ate: Signed + —'—FOR DEPARTMENT USE ONLY Date Area r� Application Accepted by 3 .Q Pit-or-Grout-Inspection.*Dodi Date�/ -- irxalinspecion-by -Date Additional Comments:❑ Stk 466-6781 369-3621 11 Manteca a23-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton'Ave., P.O. Box 2009, Stk., CA 95201 f FEE CK RECEIVED BY DATE PERMIT'N0. AMOUNT DUE AMOUNT R MIT7ED CASH INF a p �4 ? a EH 13-I4 1REV.1/K 51 - EH 1428 _