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,� • APPLICATION FOR PERMIT • SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) all the lor Application is tleieby made o the San u n Cco tyN OrU laLocal nClU No.549 for sewa(ealth District for 3 pe or11t to No 1862 forcwell/fpUR o andthethe Ri085 and rk IReOulationa of This San Joaquin made in conTptienco with SanJ oaq Local Health District./�PN 4t7 //y_ UL0 -03 _ StA) �49✓Wt/ & / t1_i& City Lot Size �— Job Address �� 14�&-Vlli / — Phone Owner's Name Gry Address ?me %n rc• ,r�� Phone_ �"6i'^�- �" N � Atfdressti00/l0u�l(Sr��' ✓�.f� License No_ iv'r.� �,(t--?l//l C�l C k¢ /r L TYPE OF WELLIPUMP NEW WELL rJ WELL REPLACEMENT l:. pESTRUCTtON `.� SNL_e3v�zhG,{1b — - PUMP INSTALLATION ❑ SYSTEM REPAIR C OTHER 3 r gtzUw Gc.1vz SEWER LINES __.— — DISPOSAL FLD-- PROP. LINE _ DISTANCE TO NEAREST: SEPTIC TANK _ OTHER WELL PITS/SUMPS = — — -- -- FOUNDATION __ AGRICULTURE WELL__--_—_ .—..—..--- — INTENDED U_$E TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS_— Dia. of Well Casing - Li Open Bottom ❑ Mantoca Dia. of Well Excavation... 1 ? Industrial _ Specifications r-i Gravel Pack L7 Tracy Type of Casing — 1 ; pomestic/Private —— Type of Grout ._--- ---• . i 1 Other Fl Delta Depth of Grout Seal - (' Public - Appfox. Depth I I Eastern Surface Seal Installed by I t Irngition - State Work Done Repair Work Done I] Type of Pump H.P. --.— ---- --_.-- - Sealing Material (top 50'1 well Destruction L? Well Diameter -- Filler Material (Below 50'1 ---- Depth :No TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIRIADDITION 1 1 DESTItUCT10fd I 1 availablerr.within 200 feet.) �t publrr sewer is Installation will Serve: Residence — Commercial -- Other -- -- Number of living units _— Number of bedrooms_ - _ Water table depth Character of soil to a depth of 3 feet: - Capacity-.. No. Compartments SEPTIC TANK F1 Type/Mfg _ -- Method of Disposal PKG. TREATMENT PLT- (-i Property Line _ Distance to nearest: Well— .._ Foundation — - — -__ Total length/size— - — -- LEACHING LINE L I No. &Length of lines Foundation —.--- Property Lire -.. FILTER BED r_1 Distance to nearest: Well — -Size -- — Number—..-- SEEPAGE PITS l Depth Foundation Property tine _ SUMPS i I Distance to nearest: Well — DISPOSAL PONDS -1 I harehy certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state lays. and rules and regulations of the San Joaquin Local Health DiWict. A or sub contracting signature Home owner or licensed agent's signature certifies the followin '1 certify that in ttw performance of the work for which this permit is issued, I shall net employ any person in such manner as to become subject to workman's compensation laws of Caled, I aemploy persons to workman's compenSa- certif certifies the following; "I certify that in the performance of the work for which this permit is issued, I shall employ p so D2� /,L tion laws of California." Sc� � late drawing on reverse side The applicant must call for all required inspections. Compds �,,,�� .��c- r Date: - Sioned �� Title: �h..n i ` " FOR DEPARTMENT USE ONLY Date _ Area - Application Accepted by Date Final Inspection by Pit or Grout Inspection by Additional CORUnenta �--� ❑ Tracy 835-6386 (: Stk 466.6781 C Lodi 369-3621 C Manteca 823-7104 ironmental Health permit/Services 1601 E. Hazelton Ave., P-O. Box 2009• Stk., CA 95201 Appflcant • Return all copies to; Env CK N RECEIVED BY OAT( PERMIT NO FEE AMOUNT OUE AMOUNT REMITTED CASH INFO _ cw n.1a1FcV ,�„,� .—_��