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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED describe(Complete in Triplicate) /or install the rk Application is hereby made to the San Jcation'is o Oftl Hance No. 549 for sewage orHealth District for a 'No. 1862 for wet to construct llldpump and the Rues and hereinR Regulations of tlhe San is l Joaquin made in compliance with San Joaquin County Local Health District. �• City Lot Size PM�--- Job Address +. '.,�� -�+, "a Phone �+ Address Owner's Name w License- S/_-3/ �-Phone�T'�V"" Contractor dress .— t WELL REPLACEMENT"❑ . DESTRUCTION ❑ TYPE OF WELLIPUMP: NEW W L ❑' OTHER ❑ PUMP IN5fALLATION ❑ � SYStTFM fdEPJ iR --z`s ,- PROP. LINE } 15 . -� SEWER•LIN ' \ �.,0 , DISPOSAL FLD. pISTANCE TO NEAREST: SEPTIC TANK _ _ ` _,1 *- !PITS/SUMPS FOUNDATION __.—�I AGRICULTURE WELL BOTHER WELL 1 !" INTENDED USE TYPE OF WEL6 PROBL� EA+I AREA CONSTRUCTION SPECIFICATIONS" w D'a. ftWell Casing _ E ❑ Open Bottom ''❑ Manteca Dia- of Well Excavation i r V O Industrial Specifications r Type of Casing p ❑4Domestic/Private ❑ Gravel Pack ❑ Tracy Depth'of Grout Seal - Type of Grout — Other �I Delta } j _ (l Public -r� ` e �Approx. Depth t 1 Eastern Surface Seal Installed by E I I Irrigation 4 �l State Work Done H.P. j Repair Work Done ❑ Type of Pump ,• Well Destruction { ❑ Well Diameter 5Z Sealing-Material Ilop50'i j 1 Depth Filler Materiak'lBelow } l TYPE OF SEPTIC WORK: NE W INSTALL4 N I I REPAIRIADDITION DESTRUCTION I I evaila No ptie y tam imi ted if public sewer is instaNation will serve: Residence Commercial— Other + Number of living';un[ts:'r� `" ''Number"of be' oms Watertabledepth Character of soil to a depth of 3 feet: No. Compartments SEPTIC TANK ❑ Type/Mfg Capacity Method of Disposal PKG. TREATMENT PLT. DI Property Line Distance to nearest: Well F undation l Total length ! LEACHING LINE ❑ No. & Length of lines property Line FILTER l3ED ❑ Distance to nearest: Well Foundation .1 2 )( 210 klI ir14 � be SEEPAGE PITS Depth Foundation istanY' SUMPS to neaPro p e Line r r � F DISP05AO PONpS ❑ " � � ,� �- E wrll be done in accordance with San Joaquin county ordinances, state laws, and I hereby certify that I have prepared this application and that the work 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, I shall employ persons subject to workman's compensa- tion laws of California." The appNcan ust call for alI uired ins ctions. Complete drawing on reverse side. J Ti\ i�` Date: Signed ti� I y FOR DEPARTMENT USE ONLY Date Area Application Accepted by j r�,,lGY Pit or Grout Inspi act by Data S�I ° "Final Inspection by .Date ✓ Additional Comments: ❑ Stk 466-6781 ❑ Lodi_.369.362_1 ❑ Manteca 823-7140._-__[1 Tracy 6335.6385 .�..,__ ,. Ise v Applicant - Raturn all copies to: Environmental al Health Permit/Services 1601 E. Hazelton Ave., P.O. Sox 2009, Stk., CA 95201 CK FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE�Q PERMIT,'NO 1 INFO U� W~l0(f b ®� + EH 13-24 IREV.1/H 51 - EH 14-26