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y.R APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED (Complete in Triplicate) work herein is r install the cation Application is her h yma to the San JoJoaaquin qry Ordinance No.549 for sewage or rNo. 1862 for welllto constructdpump and the Rules and R gulatiods of trhe Sanl Joaquin made in compliance Local Health District. .I p� / City f -_ Lot Size AL PM Job Address C U,/ ,: M L ` Owner's Name SGD X/� Address Phone 3 � � � �7 License No. S�Y�Y7 _Phone `t7 Contractor (it1 D Address//l� ��- �"!�r WELL REPLACEMENT ❑ DESTRUCTION ❑ TYPE OF WELL/PUMP: NEW WELL.❑PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES' DISPOSAL,FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ` ❑ Open Bottom ❑ Manteca Dia.of Well Excavation Dia. of Well Casing EJ Industrial Specifications .� El Domestic of Casing DomesticlPrivate ❑ Gravel Pack ❑ Tracy Deptfi of�Grout Seal Type of Grout I'1 Public ❑'Other Ll Delta C E I I Irrigation Approx. Depth l 1 Eastern Surface Seal Installed by g : ' `'~ H P State-Work Done Repair Work Done ❑ Type of'Pum Well Destruction ❑ Well Diame f Sealing Material itop 50') Depth t Filler Material IBalow 50'1 STALLATION' �REPAIRlADDITION l_I DESTRUCTION I I (No septic system permitted if public sewer is TYPE OF SEPTIC WORK: NEW IN - T available within 200 feet.) E rn.e Installation will serve: Residence Other ✓ .Commercial` Number of Living units: _�— Number of bedrooms.= Water table depth Character of soil to a depth of 3 feet: 1r_/r tf Capacity A SEPTIC TANK ❑ Type/Mfg No. Compartments „ Method.of Disposal iPKG,TRFATMENT PLT. ❑ Distance to nearest: Well Foundation_,.Property Line' y- ��' Total length/size 70 �X,y LEACHING LINE No. & Length of lines iLine 1017 FILTER BED 11 Distance to nearest: Well Foundation 3 d Property �. r' � Number Z ", SEEPAGE PITS I Depth ti Size Nb7� ; L1 Distance to nearest: Well� Foundation Property Line SUMPS I DISPOSAL PONDS ❑ his application and that the work will be done in accordance with San Joaquin co�nty ordinances, state laws, and I rules certify that I have prepared t les 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, 1 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 performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California.. t s The applicant must call for all required inspections Complete drawing on reverse side. Title: _- Date: Signed X ARTMENT USE ONLY { r I Date Area —� Application Accepted by p r' Date Final Inspectio�by' Date O Pit or Grout Inspection by �.,. Additional Comments : f LJ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 : '❑ Tracy X385 Applicant - Return all copies to: Environmental-Health Permit/Se 4ices 601 E Hazelton Ave ,0.O. Box 2009, Stk., CA 95201 I " FEE CK RECEIVED BY DATE PERMIT'NO. AMOUNT DUE AMOUNT REMITTER _,CASH INFO �j �N t �7 1XJ + + EH13-24rRMI/Hbl �� C �•G { EH 14-2B 1 r"