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APPLICATION FOR PERMIT b. ...- SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL—1 ON AVE., STOCKTON, CA I' Telephone (209) 466-6781 t41AS 1h. I PERMIT EXPIRES 1'YEAR FROM DATE ISSUED (Complete in Triplicate) ulation �ge San Joaquin /or install the �rein describeth This application is Application is helebYNmade SanoJoaqu Joaquin San Qty ouin rdinance Hance No. 549 for sewagocal Health District for a e or permit to 1862 for cwellldpump and the RujBA' made in compliance r/�rCCs'YY��/467 �Local Health OistricE. C� City �� Lot SizeJob Address � �if/d L L�O/I Pat s4>`I J+t� Address C✓l-'v1�7'"" G�•��C C�9 9�5� Phone owner's Name .rTdG�� I -Contractor --�i�yllla� Address 2�Z�.'�/ rzd� �T, License No. S�ZZ 6� Phony ~F JZ NEW WELL F1WELL REPLACEMENT ❑ DESTRUCTION ❑ L TYPE OF WELLIPUMP: SYSTEM REPAIR ❑ OTHER �Sai1- L�zy't-, V�a PUMP INSTALLATION ❑ SEWER LINES �- DISPOSAL FLD. PROP. LINE DISTANCE TO NEAREST: SEPTIC TANK AGRICULTURE WELL OTHER WELL— INTENDED FOUNDATION INTENDED USE TYPE OF:WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS pia. of Well Casing FI Industrial ❑ Open B6ttom El Manteca Dia. of Well Excavation Specifications ` Type of Casing I ❑ Domestic/Private ❑ Gravel Pack racy Depth of Grout Seal �� Type of Grout [-1 Public Other?A�+�i.o,"6❑ Delta i I I IrrigationApprox. Depth i I Eastern Surface Seal Installed by rH P State Work Done Repair Work Done [3 Type of Pump Well Destruction ❑ Weil Diameter Sealing Material Itop 501 aterial (Below 50'1 Depth Filler M TYPE OF SEPTIC WORK: NEW INSTALLATION I ! RFPAIRIADDITION l I DESTRUCTION i I availableseptic within 200 feet .) if public sewer is Installation will serve: Residence Commercial— Other T Nu Number of bedrooms Number of living units: r Water table depth Character of soil to a depth of 3 feet: No. Compartments SEPTIC TANK ❑ Type/W9 Capacity Method of Disposal PKG. TREATMENT PLT. ❑ ! Distance to nearest: Well Foundation Property Line 4 \ LEACHING LINE ❑ No. &Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line ! SEEPAGE PITS ( I Depth Size _ Number SUMPS ❑ Distance to nearest: Well Foundation Property Line r DISPOSAL_ PONDS ❑ I hereby certify that I have prepared this application and that the work will be e in accordance with San Joaquin county ordinances, state laws, and don 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." The applicant must c for all require inspections. Complete drawing on reverse side. z f Signed X Title: /�J.rr�x� Date: FO DEPARTMENT USE ONLY ' y YQ�tLR Date �3 ea Application Accepted by Pit or Grout Inspection by Date Final Inspection by Date r 2 Additional Comments: [ ElStk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 623 7104 ❑ Tracy 835 6385 1 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 F;A;M0UNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. FEECASK f INFO /Q +.EH 13-2r1REV.1/H*) "o EH N-26