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Frs .xi APPLiCATION,FOR PERMIT Fra SAN JOAQUIN LOCAL HEALTH DISTRICT D � 1601 E. HAZEL T ON AVE., STOCKTON, CA �I aj Telephone {209} 466-6781 PERMIT EXPIRES 7 YEAR FROM DATE.iSSUED ' As w:,y� .w (Complete in Triplicate) ENVIRQ!Vihl7AL HEALTH i Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work h. ,FE MI bed ERVapplie^atio' is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. . Job Address t Cit Lot Size PM Owner's Name c Address Phone Contractor Address 0 ,�� &� e License No. F _2� TYPE OF WELL/PUMP: NEW WELL Cil �� Z�. Phone WELL REPLACEMENT ❑ DESTRUCTION`❑ PUMP INSTALLATION SYSTEM REPAIR L7 DISTANCE TO NEAREST. SEPTIC TANKOTHER ❑ SEWER LINES DISPOSAL FLD. PROP. LINE R � FOUNDATION AGRICULTURE WELL OTHER WELL INTENDED USE--. TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS *P1T5/5UMP5 ❑ Industrial n ❑ Open Bottom kDomesticlPrivate ❑ Gravel Pack ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Tracy Type of Casing ❑ Public ❑ Other Specifications - ❑ Delta Depth of Grout Seal ❑ Irrigation ---Approx. Depth ' C1 Eastern Type of Grout Seai Installed by , Repair Work Done ❑ Type of Pump H p //;I,_ Wolf Destruction ❑ Well DiameterState Work Done Sealing Material (top 50'1 ' Depth Filler Material (Below 50') TYPE 0 SEPTIC WORK: NEW INSTALLATION ❑- REPAIR/ADDITION ❑ DESTRUCTION ❑ {No septic system permitted public sewer is d if i Installation will se Residence,,� Commercial, Other j available within 200 feet.) Number of living units: ' Number of bedrooms Character of soil to a depth of et: SEPTIC TANK ❑ Water table depth Type/Mfg t. Capacity�� PKG. TREATMENT PLT. L2 � - ,;{�` ..�`_)•....��,_ No. Compartments ' Distance to nearest: Method of Disposal f f Foundation Property Line LEACHING LINE ❑ No.'& Length of lines FILTER BED Total length/size ❑ Distance to nearest: Well Foundation , }Property Line . SEEPAGE PiTS ❑ Depth Size - SUMPSFoundation--� Number ❑ , Distance to nearest: Well DISPOSAL PONDS ❑ i Property Line I hereby certify that I have prepared this application and that the-- be done in accordance with San Paquin county ordinances,state laws, and rules and regulations of the San Joaquin Local Health'District. Home owner or licensed agent's signature certifies the followin � �.hat � ( ~ employ any person in such manner as to become subject to workman's comfy tpensation lawsofCaliforrnia-'Contractor's hbo,of the work for 'hiringl or sub-contracting signs permit is issued, I anot ture 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 applicant must call for all r purred inspections. Complete drawing on reverse side. Signed X Date: —/ s I FOR DEPARTMENT•-USE'O_NLY Application Accepted by r7� �� Date // J ' Area D Pit or Grout Inspection by Date /S�rrf Final Inspection by Date Additional Comments: i_ ❑ 5tk 466-6781 = ❑ 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 FEE DUE AMOUNT REMITTED CK INFO AMOUNT CASHRECEIVED BY DATE PERMIT'NO. k + 13-241REV.iia 51 � ER 14-28