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APPLICATION FOR PERMIT ` SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1'YEAR FROM DATE ISSUED (Comiw licate) j Application is hereby made to the San Joaqu L 1 Heal istrictc and r II e k h es ed/. This application is made in compliance with San Joaquin Cou r or o a t e R Ies d R tions+bf the San Joaquin Local Health District. A Job Address City t Size PM a Owner's Name 1" dress Phone 7 Z fa __ I �y�I� E -/ ��r7�j'Sj 4 Contfactorr Address c,.J! License No. LS/ Q Phone TYPE OF WELL/PUMP: NEW WELL '"—WELL REPLACEMENT El DESTRUCTION ❑ -T PUMP'INSTALLATION ❑ SYSTE REPAIR ❑ OTHER 1-1 , DISTANCE TO NEAREST: SEPTIC TANK SEWER L ES" DISPOSAL FLD. PROP. LINE 1 FOUNDATION "1 r4GRICUL RE AELL 'OTHER WELL PITS/SUMPS t INTENDED USE TYPE OF WELL PROBLEM AREA C NSTRUCTlON SPECIFICATIONS a ❑Industrial + ❑ Openr Bottom ❑ Manteca ia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private # Cl Gravel Pack ❑ Tracy Type of Casing Specifications 's 'Y f 1 Public F 1 Other 1-1 Delta Depth of Grout Seal Type of Grout ___ ,�^�:, : I I Irrigation r __Approx. Depth 1 I Eastern urface Seal Installed by i... Repair ork Done ❑ Type of Pump H State Work Done _ s �` Well Destruction ❑ ,I Weil Diameter ealing Material ltop 50'1 s Depth Filler Material I �I 50') TYPE OF SEPTIC WORK: NEW INSTALT N I 1 EPAI DDITI *1)EtTRLlCN I INo septic system permitted if public sewer is avai le wit 200 feet.) Installation will serve: Residence— Commercial Other Number of living units: Ntarribef of drooms" 'f Character of soil to a depth of 3 feet: Water table depth e SEPTIC TANK ❑ TypFr Mfg parity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal _ Distance to nearest: Well �.- Foundation Property Line ` (� LEACHING LINE ❑ No. & Length of lin Total length/size r FILTER BED ❑ Distance to nearest oundation Property Line } SEEPAGE PITS ,i 1 Depth Z4 Size N tuber ; SUMPS Ll Distance to nearest: Well Foundation M Property Line DISPOSAL PONDS �❑ I I herebycertify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and 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 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 perforrrfance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California. f ^� II The applicant call for al quired'i`specvons. Complete drawing ori reverse side. Signed X 6/ust Title: o Date: OFOR DEPPfRTMENT USE ONLY Application Accepted by r Date Area Pit or Grout Inspection y 1 Date Final Inspectio by - Dat ,... ,.._. .. _ t 1 { Additional Comments: 1 µ f ❑ Stk', 466-6781 ❑ Lodi 36,9&U1,,, `t, LI Manteca 823-7104 ❑Tracy 635-6385 ," t Applicant - Return all copies to:..I'Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201FEE t 1 INFO AMOUNT DUE AMOUNT REMITTED * CK CASH RECEIVED BY DATE PERMIT NOY R/ FC\ 09 q ZEii 13-24(REV.1/K 5) f. EH'14-26 Ki- v