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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT l 1601 E. HAZE.T ON AVE., STOCKTON, CA Telephone (209) 466-6781 °ws�6 f Rte] PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) ribe . This all the work Application1lance with a to the San n Joacation is gty Ordinance uin lNo.549 for sewage ealth District for a permit 1862 for well/pump and the Rules and hereinR Regulations of the San'Joaquin made p Local Health District. 72 C1 t4 _ �� 7 � r�a �U City Gf� Lot Size PM Job Address 9�3,_ dAddress _t �/ ` ' Phone / Owner's Name 4 /57 W. T V° 7 0-c. � 08 334-D�b�3 $ Address_ �-� � - Phone License-No.��-- Contractor � TYPE•OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ �7 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTA-NCE-TO-NEAREST:-SEPTIC-TANK SEWER LINES „=,,,�'—DISPOSAL FLD. PROP. LINE G . FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Private ❑ Gravel Pack ❑ Tracy Type of Casing /� Specifications icl omest _ _ ❑ D , . Type of Grout YP f'1 Public Cl Other ❑ Delta Depth of Grout Sea{ - � I I Irrigation —.-Approx. Depth l I Eastern Surfade"Sual installed by ` H P. State Work Done Repair Work Done Ll Type of Pump 1 Well Destruction ❑ Well Diameter Se king Material (top 501 _ Depth Filler Material IBelow 50') �. t TYP.E70F SEPTIC WORK_ NEW INSTALLATION I REPAIR/ADDITION l I DESTRUCTION II 8lvailase lipelwithin sysm 200 feeft� ed if public sewer is I Installation-will serve: -Residence al Other k !Number of-living units:-- Number of bedrooms I Water table.depth. Character of,soil to a depth of'3 feet: �� t `Ga'paci y—` '�� No. Compartments SEPTIC-TANK -Type/Mfg- t� Y .- f-- —Method of-Disposal r- , I PKG.:TREATMENT'PLT"❑ t A` rD ell_ Foundation_ � .Line Distance-to nearest:- W 1 Property ---LEACHING-L-INE -17-1 --No.•8-Length-of-lines 4-7 - Total length/'size FILTER BED CI {Distance to nearest: Well ._. Foundation Property Line Property n f SEEPAGE PITS I I Depth Size gyp! « � Number Property Line SUMPS CI Distance to nearest_ Well _ Foundation - , DISPOSAL PONDS ❑ r' J hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and k 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 I[ 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,1 shall employ persons subject to workman's compensa tion laws of California." The applicant mus squired inspections. Complete drawing on reverse side. j � Signed X Title: �^" Date: FOR DEPARTMENT USE ONLY Data Area Application Accepted byY!G Date Final inspection by Date G 0 1 Pit or Grout Inspection by � g� Additional Comments: D' ❑ 5tk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ED Tracy 635-6385 I Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 L r FEERECEIVED BY DATE PERMIT NO. AMOUNT DUE AMOUNT REMITTED INFO +-EH 1324 I REV.1/R 51 EH 14-28 -