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,I APPLICATION FOR PERMIT p I� SAN JOAQUIN LOCAL HEALTH DISTRICT �W J S IB J � 1601 E. HAZE T ON AVE., STOCKTON, CAS �I Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED V!,��[�5��4 i in Triplicate) I� (Complete it Application haenee wma San Joaqthe uincation is Ordinance No. 549 for sewage o uin Local Health District for a permit 1862 for weli/dpumlp and the Rules and Regulations of the San`Joaquin made In P if Local Health District. . / !I L� City � "fesof Size PM Job Address OZ R z o !'2 ,¢ I ;;f% G3-icy/ Owner's Name { �G'r Address _ O tie Phone I I' 6�v` License No. Phone Contractor N 1/G a Address TYPE OF WELL/PUMP: EW WELL Ll WELL REPLACEME ❑ DESTRUCTION 1:1 E - PUMP INSTALLATION ❑ "" SYSTEM REPAIR OTHER 111 k + SEWER LINES DISPOSAL FLD. POOP. LINE DISTANCE TO NEAREST: SEPTIC TANK T ' PITS/SUMPS FOUNDATION AGRICULTURE WELL. OTHER WELL r INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS , Dia. of Well Casing i ❑ Industrial ❑,Open Bottom El Manteca Dia- of Well Excavation Type of Casing t Specifications X. - Domestic/Private•�" 1711 Gravel Pack ❑ Tracy � = Type of Grout f'1 Public (_],Other [-I Delta Depth of Grout Seal Surface Seal Installed by it _Approx. Depth l i Eastern I 1 Irrigation =- Work Done_' State Repair Work Done ❑ Ty" of Pump s� H.P. n Well Destruction ❑ Well Diameter _�L--_.— Sealing Material (top 501 1 k Depth Filler Material (Below 501 1 TYPE OF SEPTIC WORK: NEW INSTALLATION I Z REPAIRIAODITION I 1 DESTRUCTION I I ac system Neilabptic hit 200 leetitled if public sewer is Installation will serve: Residence, Commercial_ Other ,. A Number of living units: Number of.bedrooms ` Character of soil to a depth of 3 fleet: Water table depth SEPTIC TANK ❑I Type/Mfg-� Capacity No. Compartments e• "*—t f PKG. TREATMENT PLT. ❑ " , Method of Disposal t Distance to nearest: Well Foundation :Property Line LEACHING LINE '❑. No. & Length of lines _ Total l.1.'o size FILTER BED ❑' Distance to nearest: Well Foundation tProperry Line," t f SEEPAGE PITS l 1' Depth Size Number I .Pro a Line . SUMPS di Distance to nearest:."- Wel Foundation p �Y _ - r DISPOSAL PONDS ❑. I hereby certify that l have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and 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 which 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 hiring or sub-contracting signature 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- tion laws of California." li The applicant mus f equire d inspec ns. Complete drawing on reverse side. .. Titla� �e2 . Daterri -8g Signe / i ry F DEPARTMENT USE ONLY Application Accepted ° Date( — Area Appl ted by p II DataT3-71 Final Inspection by41 Date 7 Pit or Grout Inspection by Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑:Mante ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE CK RECEIVED BY DATE PERMIT NO. AMOUNT DUE AMOUNT REMITTED CASH INFO +.EH 13-24(REV.5/e 5) / q EH t/-2e t I