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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE-t!STOCKTON, CA Telephone (209) 466-6781.: _ PERMIT EXPIRES 1 YEAR FROM DATE ISSUED --------------- r. :` �' (Complete in Triplicate) ication is Application is hereby made to the San JoeCounquin ty Ordinance No.District Health 549 for sewage ar permit to 1862 forcwelllpump and the Rules and Regt and/or install the work herein u described. of the San Joaquin made in compliance with San Joaquin ;s -4�� _ Local Health District. 1' i4VL1 �' 'To"f X��j PM y L� „�, City Lot Size f ! Job Address27 _ — Address "" Phone Owners Name �_, ��y� /��'P �� I Z �l r �� R�fl.� c�"�� —Phone k Contractor dress +cense No. TYPE OF WELL/PUMP: NEW WELL ❑air= WELL REPLACEMENT Q DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ SEWER LINES DISPOSAL FLD. PROP. LINE DISTANCE TO NEAREST: SEPTIC TANK ' FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of1.Well Casing ttom ❑ Manteca Dia. of Well Excavation ❑ Industrial © Open Bo , 7 of Casing Specifications Q Domestic/Private ❑ Grave) Pack E3 Tracy Y� g T of Grout © Public ❑ Other ❑ Delta Depth of Grout Seal Type ❑ Irrigation _--Approx. Depth ❑ Eastern Surface Seal Installed by f \ Repair Work Done ❑ Type of Pump H P State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 f Depth Filler Material (Below 501 f TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION VDESTRUCTION 0 (No septic system m permifeet}ed if public sewer is available Installation will serve: Residence Commercial_ Other. Number of living units:_1— Number of bedroom _,�_— /��} Character of soil to a depth of 3 feet: Water table depth`j—=s� SEPTIC TANK ❑ Type/Mfg " Capacity No. Compartments Method_ of Disposal i PKG. TREATMENT PLT. ❑ { Distance to nearest; Well Foundation Property Line 1P 42 f Q - Total length/size LEACHING LINE �NO. & Length of lines � r property Line FILTER BED ❑ Distance to nearest: Weil iFoundation y�I,t 5iie------------- Number SEEPAGE PITS ❑'i Deptli`1i�_ 1 SUMPS —' Property�Uineuistance to nearest: Well�. FoundationI DISPOSAL PONDS ❑ .. { I hereby certify 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.&�,-,," 4 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 n employ any person in such manner n to become subject-to workman's compensation laws of California."Contractor's hiring or sub-contracting signature k performance-of the work for,which this permit is issued,I sfiaflwemploy persons subject to workman's compensa- certifies the following:"I certify that in the performantion laws of California." The applicant mu ti all fo all re red in ctions. Complete drawing on r verse side. Title: � Date: Signed t FOR DEPARTMENT USE ONLY Area Application`Accepted by _16 I ____ �r Final Inspection by Date Grout Inspection by Dat [� d itional Coommments: ❑ Tracy ❑ Stk 466-6781 µ. E3 Lodi 369 1 El Manteca 823-7104 cY Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2. 009, Stk., CA 95201 1 CK RECEIVED BY DATE INFO PERMIT NO. FEE AMOUNT DUE AMOUNT REMITTED CASH +EH 13-24)REV.1/8 51 EH W2e a F d0 r