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APPLICATION FOR PERMIT 1 lYg SAN .fOAnUIN LOCAL HEALTH DISTRICT --�� 1 E. HAZE�TON AVE., STOCKTON, CA -. 160 M Telephone (209) 466 6781 PERMIT 1<XPIRES.T YEAR FROM DATE ISSUED r,y ;1F"_,�� ' (Complete in Triplicate? !�P y' ' hcation is . No. 1862 for welllpump and the Rule's'and fiegulatioris of the San Joaquin Joaquin Local Health District for a permit to construct and/or install the work herein`de lata ed.lThes-apP Application is hereby made to the San Jouq , made in compliance with San Joaquin County Ordinance No.549 for sewage or r' € PM Local Health District. ;s t J_ r Vis' . : tat Size x City p ty "7 ' 00 V Phone Job Address Address Owner's Name T�, 46i3`Ira — Phoneme License No. � fAddress f DESTRUCTION Contractor WELL REPLACEMENT ❑ OTHER ❑ NEW WELL ❑ TYPETF WELL/PUMP: SYSTEM REPAIR C] pROP. LINE PUMP INSTALLATION i DISPOSAL FLD.��— .SEWER LINES ---� PITSISUMPS_ - OTHER WELL DISTANCE TO NEAREST: SEPTIC-TANKT-._ � AGRICULTURE WELL FOUNDATION 1 0 r TYPE OF WELL PROBLEM AREA �'' CONSTRUCTION SPECIFICATIONS Dia of Well Casing INTENDED USE --�� pia. °f Well Excavation t C1 open Bottom ❑ Manteca Specifications El Industrial ❑ Tracy Type of Casing Type of Grout pomestic/Private Il Gravel Pack [� Delta Depth of Grout Seal � l'1 Public Cl Other ` Surface Sed! Installed by ! I i Irrigation �— Approx. Depth i 1 Eastern State Work Done- Repair Work Done ❑ Type Of Pumpl=— Sealing Material (top 50') ` Well Destruction © Well Diameter .��-= Filler Material (Below 50Q f Depth '1 available within 200 feet.) d TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 RFPAIRIADD1.. l 1 DESTRUCTION i ! (No septic system permitted if public sewer rs LL_ Commercial— Other r Installation will serve: Residence Number of living unite: Number of bedrooms --- Water table depth` 5, Character of soil to a depth of 3 feet: Capacity--� No. Compartments SEPTIC TANK ❑ Type/Mfg Method of Disposal PKG. TREATMENT PLT. El Foundation_� .Pfoperty-Line • . Distance to nearest: Well ��-- Total length/size LEACHING LINE ❑ No. & Length of lines Foundation property Line �— F FILTER BED ❑ Distance to nearest: Well �� _ Number 4 I Depth Size '` Property Line I SEEPAGE PITS Foundation� IL SUMPS Ll Distance to nearest: Well -_1 nd DISPOSAL PONDS ❑ certify that I have prepared this application and that the work will be done in accordance with San.J°fou which thisounty Permit is issued I shallstate laws, not of 1 hereby Y rules and regulations of the San Joaquin Local Health District. I certify that in the performance of the work i Home owner or licensed agent's signature certifies the following: " y compensation laws at California." Contractor's hiring or sub-contracting signature employ any person in such manner as to become subject to workman's comp certifies the following: '�I certify that in the performance°f the work for which this permit is issued, I shall employ persons subject to workman's compens - tion laws of California. f Il for alltrequired inspections. Complete drawing on averse side. Date: The applicant ,.? i Title: Signed FOR DEP ENT SE ONLY D L r Area Date I Application Accepted by Date�� S Date_1 Final Inspection by Pit or Grout Inspection by Additional Comments: ❑ Trac 835-6385 Stk., CA 95201 ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823 7104 Y Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, w CK RECEIVED BY DATE PERMIT'NO. FEE AMOUNT DUE AMOUNT REMITTED CASH 1 INFO { l ♦.EH`13-24fREV.,rN$1 EH 14-26 ` ----- i