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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 (Complete in Triplicate) and/ Application is hereby made to the San Joaquin Local Health District for a permit to constructor install the work herein described.This application s ump and the Rules and Regulations of the San Joaquin made in compliance with San Joaquin County Ordinance fore a or No. 1862 for well/p Local Health District. t� `� Q j ��p/✓ • City�� Lot size— / 59 PM Job Address CY " ��f �-6 49IiII �_J'_ Phone `2`�� r 6 CJ �— ` Address Owner's Name �y1 '�h !AL Phon /�t(1 r Address Go /License No. Contracto , REPLACEMENT ❑ DES WELLTRUCTION ❑ _ �q NEW WELL ❑ OTHER TYPE OF WELL/PUMP: SYSTEM REPAIR ❑ ZA —�— WMP INSTALLATION DISPOSAL FLD SE `;� PROP. LINE SEWER LINES � - OTHER WELL�7�— PITS/SUMPS DISTANCE TO NEAREST: SEPTIC TANK TURE WELL 4// FOUNDATION INTENS E TYPE /p ROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia of Well Casing ET-0 pen Bottom' / ❑ Manteca Dia. of Well Excavation ❑ Industrial �`*dL. Specifications ❑ Tracy Type of Casing �T— T { rout Gravel Pack ❑ Domestic/Private � ❑ Delta Depth of Grout Seal ❑ Public ❑ Other I �pprox. Depth ❑�stens Surface Seal Installed b CCVi ❑ Irrigation Y7C-iH.P, State Work done 7_/1` rn Type Of Pump � r"['S ��d>P_ v Repair Work Done ❑ Sealing Material(top 50'1 ] • Well Des ruction ❑ well Diameter DePth Filler Material (Below 50) N�crvJ �� available within 2011 feet.) TYPE OF SEPT WOjRK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ INo septic system permitted if public 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 ❑ Type/Mfg Method of Disposal PKG. TREATMENT PLT. ❑ - property Line Distance to nearest: Well Foundation Total length/size LEACHING LINE ❑ No. & Length of lines Foundation Property Line FILTER BED ❑ Distance to nearest: Well Number ❑ Depth Size Property Line SEEPAGE PITS Foundation SUMPS ❑ Distance to nearest: Well r DISPOSAL PONDS ❑ I hereby cartfi'that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances,state laws, an rules and regulations of the San Joaquin.Local Health District. .I certify that in the performance of the work for which this permit is issued, 1 shall not Home owner or licensed agent's signature comes the following: ' nation laws of ed,I sal Contractus iring or subject t workman's compensa- employ any person in such manner as to become subject to workman s compoCalifornia." 1 shall employ persons certifies the following:"I certify that in the performance of the work for which this permit is issued, tion laws of California." S �/�'7rr The applicant must call r all rluired inspections. Complete drawing on reverse side. Date: !t�— ��0��i Title: A[ Signed � FOR DEPARTMENT USE ONLY j2A� — Dafye�/ Area tion Accepted byl � (/ ( � DateApplica /21$ Final Inspection b Date Pit or Grout Inspection.by �le� ��• � Additional Comments: C3 Lodi 3621 ❑ Manteca 823-7104 C1 Tracy 83`x6385 [3Stk 466-Ml Applicant- Return all copies to: Environmental Health Pemlit/Service s 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 9 k DATE PERMIT'NO. FEE AMOUNT DUE AMOUNT REMITTED C RECEIVED BY INFO � a EH 13-24 1REV.1/0 5) FH 14ffi