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APPLICATION FOR PERMIT C Tt 7 -� i,SAN'�JOAQUIN LOCAL HEALTH DISTRICT '60 1E HAZELTON-AVE., STOCKTON, CA HID P+Vf Telephone (2091 466 6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED CI,MRM,4ENTAL HEALTH (Cornplete in Triplicate) FERMIT/SERVjCES application is is County Ordinance No.549 for sewage or No. 1862 for welllpump and the flutes and Regulations of the San Joaquin ade to the an Application is hereby mSJoaquin Local Wealth District for a permit to construct and/or install the work herein described. This app made in compliance with San Joaquin Local Health District. / e � - 11✓l .City i�Size PM Job Address t. I P Phone Address aOwner's Nam f r 6 L.Icense No.fa3z Phone_ vw✓� Contract V� Address ® DESTRUGTlON ❑ TYPE OF WELLIPUMP: EW WELL ❑ WELL REPLACEMENT ❑_/" PUMP INSTALLATION ❑ SYSTEM REPAIR L 1 OTHER ❑ SEWER LINES _.�— DlSPQSAL FLD. PROP. LINE DISTANCE TO NEAREST: SEPTIC TANK OTHER WELL PITS/SUMPS FOUNDATION AGRICULTURE WELL t TYPE OF'WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS INTENDED USE Dia. of Well Casing Dia. of Well Excavation i ❑ Industrial fl Open Bottom Ll Manteca f Specifications Type of Casing _ ❑ Domestic/Private ❑ Gravel ck ❑ Tracy Depth of Grout Seal f Type of Grout - (-1 Other ❑ Delta _ M Public Surface Seal Installed by I 1 Irrigation Approx. Depth �I,I Eastern State Work Oone F � e of Pump �--��J N.P. - Repair Work Done Typ Sealing Materia! (top 501 Well Destruction ❑ Well Diameter Depth I Filler Material (Below 501 _ ^r TYPE OF SEP71G WORK: NEW INSTAtLAT10N l 1 REPAlR A,�OD TI JN lZLy4DE5TRUCTION;[ I a ailablerwi within 200 feet.) if public sewer is Installation will•serve'- Reside e— Cbmmerc�ai�`—Other _ 1 Number of living units: Number of bedrooms Water table depth Character of soil to a depth of 3 feet: :' No. Compartments SEPTIC TANK ❑ Type/Mfg aJ m (f .4 Capacity i - j Method of Disposal I PKG. TREATMENT PLT. ❑ Property.Line Distance to nearest: Well_—� FAundation 1 Total length/size 1 LEACHING LINE ❑ No. Er Length o1 lines Foundation Property Line FILTER BED ❑ Distance to nearest: Well ' Size Number` SEEPAGE PITS 11 Depth 4 11 Foundation I Property Line SUMPS ❑ Distance to nearest: Well DISPOSAL PONDS ❑ I hereby certify that r have prepared this application and that the work will be done in accordance with San JoaquinLcounty ordinances, state laws, an rules and regulations of the San Joaquin Local Health Di§trictnot. work for this Home owner or ' ense nit's gas torbecomfiesUbhleC�Ito w kman'srtcompensafon laify that in the ws of California."rmance Contractor'slhhing or sub-contracting signature employ any p son in such ermit is issued, l shall employ persons subject to workman's campensa- C+artifies the f flowing:"'I Corti at in the rf a e the ork for which p 1 tion laws of California.;' dr ing o re si e. The applic t mus aA required ns ((( � ills: Date: Signed X FORD RTMENT USE ONLY — Date J Area I Application Accepted by Z46 VZ-P Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ Manteca 823-7104 ❑ Tracy 835-6385 ❑ Stk 466-6781 L3 Lodi 369-3621 alth Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 Applicant- Return all copies to: Environmental He CK RECEIVED BY DATE PERMIT'NO. FEE AMOUNT DUE AMOUNT REMITTED CASH )NFO +,EH 13-24(REV. i e sl 3 7 EH 1428