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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1 1601 E. HAZEL T ON AVE., STOCKTON, CA 11 Telephone (209) 466-6781 C,1 k PER EXPIRES 1 YEAR FROM DATE ISSUED k�_ . [Complete in Triplicate! i application is i ! n Ordinance No.549 for sewage or No.1862 forwell/pump and the Rules and Regulations of the San Joaquin Application is hereby made to the San Joocaquin Local Health District for a permit to construct andlor install the work herein described. s made in compliance with San Joaquin County Local Health District. j-j�EA)C'H PM C City Lot Size Job Address Phone i Address Owner's Name wATIe Phone License No. Contractor's Name ELL/ WELL REPLACEMENT LJDESTRUCTION ElJ� r, TYPE 01' PM UP: NEW WELL 11 WELL ❑ . - TEM REPAIR,❑ i PUMP INSTALLATION l� 'SEWER �_-'- `L LINES —� DISPOSAL FLD. PROP, LINE DISTANCE TO NEAREST:TO TANK �� OTHER WELL r- PITS/SUMPS FOUNDATION l— AGRICULTURE WELL INTENDED USE TYPE OF WELL PROBLEM CONSTRUCTION SPECIFICATIONS Dia of Well Casing ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Specifications 13lndustrial Tracy Type of Casing omestic/Private ❑ Gravel Pack ❑ Type of Grout r ' ❑ Other ❑ Delta Depth of Grout Seal [I Public Surface Seal installed by �� ❑ Irrigation ---Approx. Depth ❑ Eastern '/ State Work Done of Pump - H.P. Repair 'Work Done ❑ Type Sealing Material (top 50'M Well D struction ❑ Well Diameter /. ' Depth Filler Material IBelow 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIRIA IDITION ❑ DESTRUCTION ❑ aNail bpe�wtsystem n$200 feet.) if public sewer is Other Installation will serve: Residence—. Commercial Number of living units: Number of bedrooms Water table depth Cha Veter of soil to a depth of 3 feet: Capacity_1 No. Compartments (� SEPTIC TANK ❑ Type/Mfg Method of Disposal A/ 1`� PKG. TREATMENT PLT. ❑ a`tion_ Property Line �Wei1 I Distance to nearest: ti I 3 i Total lengthlsize LEACHING LINE ❑ No. & Length of lines property Line - •—�----•t=aundation FILTER BED ❑ Distance to nearest: Well j i Number ❑ Depti Size _. SEEPAGE PITS h s ,,- Foundation Property Line SUMPS El 'Distance to nearest: Well DISPOSAL PONDS ❑ �— I hereby certify that I have prepared this application an$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. I that in the performance of the work for which this permit is issued, I shall not Howie owner or licensed agent's signature certifies.the following: " certifyof rsons subiect to workman's compensa- A employ any person in such manner hat s to the become 64 )a a�b- A to workman's nte tsf he work for which this permit is issued l shaA employ pe Contractor's hiring or sub contracting signature � cert'rf„„les the following:"I certify --tion;,laws-of-Califomia:"—"--'”' r r L verse, The II f ll reinspectons. complete drawing on reve. applcw % .• Date. + :,Ttle" .;.. Sig led 4� '4t i FOR DEPARTMENT USE ONLY Area., Date Application Accepted - i I Date Final Inspection bya Pit or Grout Inspection by i r Ad ldtional Comments: fl Tracy--835-S3$5 '"`� C1Stk-'-466-6781'- 'G-Lodi-369-3621-•----^--❑-Manwes-823-7104 ApplicantReturn all copies to: Environmental Health Perrot/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 CK DATE f ERMIT`'NO. F AMOUNT REMITTED CASH RECEIVED BY FEE AMOUNT DUE INFO +EH 132410183! - EK 14-21111