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�r! APPLICATION FOR PERMIT , SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE_ STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 11 YEAR FROM DATE ISSUED (Complete in Triplicate) This application is permit to construct andlor install the work herein described' ' e Joaquin County Ordinance No.549 far sewage or No.1862 for welly pump and the Rules and Regulations of the San Joaquin Application is hereby made to the San Joaquin Local Health District for a pe I made in compliance with San Jo q i Local Health District. Stij Lot Size sox 1.OB PM S 7� City Job Address Phone \ AU Address Owner's Name -_ - Yr yy4 phone Gt 77/ Ott!AA! ✓6 License No. ZCf Address� � DESTRUCTION ❑ For 11111111 Contractor WELL REPLACEMENT ❑ NEW WELL ❑ OTHER ❑ TYPE OF WELL/PUMP: SYSTEM REPAIR IDPROP. LINE PUMP INSTALLATION ❑ DISPOSAL FLD. SEWER LINES k f PITS/SUMPS DISTANCE TO NEAREST: ,SEPTIC TANK'�� AGRICULTURE WELL OTHER WELL FOUNDATION TYPE OF:WELL 4 PROBL�A-�.-CONSTRUCTION SPECIFICATIONS I Dia. of Well Casing INTENDED USE _ -;❑ Manteca' ,z.Dia. of Well Excavation s Specifications f ❑ Open Bottom Ilk t Type of Casing ❑ Industrial . •❑ Tracy Yp Type of Grout ❑ Domestic/Private ❑ Gravel Pack, 1 Depth of Grout Seal !? k ❑ Public ❑ Other _, Delta app ox, Depth , E Eastern Surface Seal Installed by \ ❑ Irrigation 'N A H.P. State Work Done Type of Pump _ — 1 Repair Work Done ❑ Yp — -^�"'"; Sealing Material (top 50`1 Well Destruction ❑ Well Diameter (No septic system per Depth Filler Material (BeI6ly 50'} rmitted if public sewer is A available within�200 feet.I TYPE OF SEPTIC WORK: NEW INSTLLATION PA'IP�ADDITiON ❑ DESTRUCTION Commercial 6 Other�J , Installation will serve: Residence Number of living units: • Number of bedrooms*_�__ _ _.1 Water table depth Character of soil to a depth of 3 feet: V; i Capacity�� No. Compartments I SEPTIC TANK ❑ Type/Mfg ; Method of Disposal PKG. TREATMENT PLT. ❑ i F Foundation Property Line r Distance to nearest: Well�a Total length/size LEACHING LINE ❑ No. & Length of lines property Line Foundation�— FILTER BED EDDistance to nearest: Well F ' f Number h Size ❑ Dept SEEPAGE PITS x Foundation�— Property Line SUMPS ❑ -Distance to nearest: Well DISPOSAL PONDS : ❑ ordinances, state laws, and I hereby certify' I have prepared: is application and that the work will be done ins accordance with San Joaquin county that in the performance of the work for which this permit is issued, I shall not rules and regulations of the San Joaquin Local-Heahefollorict " Homo owner or licensed agent's signature certifies the following: "I certify nation laws of California." Contractor's hiring or sub contracting signature employ any person in such manner as to become subject to workman's comps certifies the following: '.l certify that in the p`erformance,of;the work for-which this permit is issued,I shall employ persons subject to workman's compensa- tion laws of California. The applicant must tali for all required inspections. C plate drawing on reverse side. Date: Title:— Signed FOR DEPARTMENT USE ONLY Date_ Area 2 Application Accepted by Rate Date Final Inspection by Pit or Grout Inspection 'p �S Additional Comments: Manteca 823-71 ❑ Tracy 835-6 ❑ Stk 466-6781 ❑ Lodi 369 3621 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave.. P.O. Box 2(109 Stk•, CA 952 01 j RECEIVED BY DATE PERMIT-NO. FEE AMOUNT DUE AMOUNT REMITTED CASH INFO c g- � " +EH 13.24{REV.1/8 5) EH 1428