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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA ' Telephone (209) 466-67,81 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) 0 work n describe . is cation is r install th madecation in is eiebnce with SanoJoaquin San C o Qty Ord nalnce No.549 for sewage or Health District for a permit 1862 for we l/puomp and the Rules and(Regulations of tthe San l Joaquin i Local Health District. }} 2 (�3 5 ,S4-n G City t lt Lot Size PM Job Address 41, Z Address Zf Phone Owner's Name 1I _/ c! Contractor V' 41 ptima Address r �-U 4ge License No.3(00� Phone 4 TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION.F– SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS f S/� El industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Cp l Domestic/Private 4L Gravel Pack El Tracy Type of Casing Specifications Other, fl Delta 547e- Depth of Grout Seal d r Type of Grout �`l Public �p,0 I I Irrigation �Approx. Depth l I Eastern Surface Seal Installed by f?�Cr'll Repair Work Done ❑ Type of Pump H.P,—� State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 501 -- TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION i I DESTRUCTION l I [No septic thin system permitted it public sewer isavailabL Installation will serve: Residence, Commercial Other T 1 I Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS i I Depth Size _ Number a SUMPS Ll Distance to nearest: Well Foundation Property Line z DISPOSAL PONDS ❑ I 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�1 ` rules and regulations of the San Joaquin Local Health DiMrict. f rtify that in the performance of the work for which this permit is issued, L shall not Home owner or licensed agent's signature certifies the following: "I ce employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature l 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 applica call for all r quired spections. Complete drawing on reverse side. Signed X Z Title: Rate: F Ft DEPARTMENT USE ONLY r Application Accepted by Date rea Pit or ou Inspection byA3� Date Final Inspection b D�� I :Additional Comments❑ Stk 466-6781 ❑ Manteca 823 7104 ❑ Tracy Tracy -ab-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED C SH RECEIVED BY DATE PERMITNO. [� q 1 300 1 + EH 13-241REV.ti1151 1 �� 1�� ,�./� qq�p 1� J �]'��- (d -, EH 14-2d L