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APPLICATION FOR PERMIT �'L1A cid - S �-�—; r SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA (ruc�t _/+ 7 Telephone (209) 466-6781 ' PERMIT EXPIRES 1 YEAR FROM DATE ISSUED its 1`J (Complete in Triplicate) Application is he+eby made to the San Joaquin Local Heal District for sewage or permit and/or No. 1862 for welllpumlhereinnstall the work p and the Rules s and R gulations of the Sant Joaquin made in compliance with San Joaquin County Ordinance Local Health District. City Lot Size PM Job Address /,yPhone t#-C� j Address. " Owner's Name�u�.-„.,--� 2 Phone _ ! f 014 Address jA License No. Contractor DESTRUCTION NEW WELL ❑ WELL REPLACEMENT ❑ TYPE OF WELL/PUMP:. - SYSTEM REPAIR ❑ OTHER ❑ PUMP INSTALLATION ❑ �„ r,_.-,......-.-p1SP05ACFLO"�"""""' �PROP'LINE�""� -. SEWER LINES' PITSISUMPS i DISTANCE'TO'NEA REST: SEPTIC TANK AGRICULTURE WELL OTHER WELL FOUNDATION INTENDED USE TYPE OF WELL PROBL_ EM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing ” w ❑ Open Bottom Q Manteca Dia. of Well Excavation ( V ❑ Industrial Type of Casing Specifications , ` ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Grout P - f I� 'Other n Delta Depth of Grout Seal l`l Public .. -� -." r- Surface Seal installed by t Approx. Depth I I Eastern s I i Irrigation H.P. State Work Done — - Repair Work,-Done 0 Type of Pump "" 1 Sealing Material (top 50'1 z 1 t� Well Destruction El 'Well Diameter . Filler Material (Below 50'1 9 ' I Depth i TYPE OF SEPTIC WORK: �NEW INSTALLATION l l REPAIR/ADDITION l 1 DESTRUCTION availablperw thine200 feet,)ed if public sewer is FIIIt ' Installation will serve: Residenc="""CiSrrtinercial= Other I Number of bedrooms Number of living units: d Water table depth Character of soil to a depth of 3 feet: Capacity No. Compartments F SEPTIC,TANK ❑ "'Type/Mfg, + Method of Disposal 1 PKG. TREATMENT PLT. ❑ r r Property Line r rest:w oundation Di Mance to neaWell f= E Fi Total length/size # LEACHING LINE ❑i Noi-A-Lengthlof lines Property Line' •FILTER BED ❑' Distance to pea st: Well Foundation P Y + i Size Number. i. SEEPAGE PITS I lil Depth i SUMPS Cl Distance to nearest: Well Foundation Property Line 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 Yaws, and rules and regulations of the'San Joaquin Local Health District. Name 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 signature s a not Home :any person in such manner as to become subject to workman's compensation laws of California." Contractor'sphiring ject to woor �kmants9ompe sa- certifies the following: "I certify that in the performance of the work for which this permit is issued,I shall employ p a tion laws of California." !' The applica t must all for.�all required inspections. Complete drawing on reverse side. Title: Date: ZZA Signed X f FOR DEPARTfNENT USE ONLY -_ /—� j G i Date Area l Application Accepted by Pit or Grout Inspec by; Data Final Inspection by Date F Additional Comments: ❑ Stk 466-6781 D'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 ' CK INFO FEE AMOUNT DUE AMOUNT REMITTED `CASH RECEIVED BY DATE PER�QMIT NO. 00 ,�, + EH 13-24 IREV.��a 5Y EH 14-Ia