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APPLICATIONFOR PERMIT MAR 2 0 SAN JOAQUIN LOCAL HEALTH DISTR41/IRONME fTAL � Ar ' 1601 E. HAZELiON AVE., STOCKTON, CA PERMIT/, l Telephone (209) 466-67$1 5ER1It', f, PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) application is r sewage or No. 1862 for well!pump and the Rules and Regulation made in compliance with San Joaquin Cos of the San Joaquin Application is hereby made to the San Jot, Locance Health District permit to construct and/or install the fo for agwork herein described.ThisSa Ordin 549 Local Health District. PM Cit J t Size Job Address Awl ( O C� Phone s dress - Owner's NameI f I l License No. Phone dds Contract � WELL REPLA EMENT ❑ DESTRUCTION ❑ TYPE OF WELLIPUMP: ��NEW WELL ❑ OTHER ❑ SYSTEM REPAIR ❑ PUMP INSTALLATION DISPOSAL FLD. PROP. LINE SEWER LINES ��- PITS/S ----UMPS DISTANCE TO NEAREST: SEPTIC TANK AGRICULTURE WELL O.T.HER-WELL-_—�- I� FOUNDATION- �=— INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS pia. of Well Casing ` pia. of Well Excavation ❑ Industrial ❑ Open Bottom ❑ Manteca Specifications � r d Tracy Type of Casing `��gp,estic/Private ravel Pack Type of Grout I / N Other C1 Delta Depth of Grout Seal l`l Public f ,.Approx. Depth 4 I Eastrn Surface Seal Installed by r i I Irrigation i State Work Done— Type of Pump H.P. Repair Work Done ❑ Typ Sealing Material (top 50'1 Well Destruction ❑ Well Diameter -- O Depth Filler Material (Below 50') — t available within 200 feet.) TYPE OF SEPTIC WORK: NEW INSTALLATION t'1 REPAIR/ADDITION I 1 DESTflUCTION I l Mo septic system permitted if public sewer is lCommercial— Other�--- f installation will serve: Residence� � 1 Number of living units: Number of bedrooms Water table depth Character of soil to a depth of 3 feet: Capacity� No. Compartments SEPTIC TANK ❑ Type/Mfg . r Method of Disposal I PKG, TREATMENT PLT. ❑ 1. DistancL�� Property Line e to nearest: Well Foundation_—�—. �J Toial length/size r LEACHING LINE ❑ Na. & Length of lines -�- ` Property Line FILTER BED ❑ #Distance to nearCssf:Well � Foundation Sizetze .. Number {� SEEPAGE PITS I I Depth/ Sit Property Line jT SUMPS Ll Distance to nearest: Well Foundation - "£DISPOSALPONDS ❑ I hereby certify that 1 have prepared this application and that the work will be done 'in with San Joaquin county ordinances, state laws, and n accordance rules and regulations of the San Joaquin Local Health Di'strict.owing Home owner or licensed agent's na gas tobecome subject Ito workman'srtcoympensat on 1that in the w soof California." Contractor's rhiring r or sub-contracting signatuI shall �e employ any person arsons subject to workman's compensa- tion the following: "I certify that in the performance of the work far which this permit is issued,I shall employ p I tion laws of California." Z The appca ust c a required inspections. Complete drawing on r arse si li f 10i Title: /[® Title: Sign F R DEPARTMENT USE Date Area 21Application Accepted by Date Date Final Inspection by.. Pit or Grout Inspection by Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 © Manteca 823.7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 nf� CK RECEIVED By DATE PERMIT NO. C�`1 FEE AMOUNT DUE AMOUNT REMITTED CASH INFO EH 13-24 1 REV.I/ 51 EH 14-26