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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT .. 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) t an /or inall the work n describe . This cation is madlecnt compliance with Sanade toJoaqu nthe San CouJoanty Ordinance No.549 for sewage or uin Local Health District for a permit 1862 for cwell/pump and the Rules and'R gulations of he San l Joaquin Local Health District. ff 02 E. 6 r'dn�l 1 vie City '�- Lot Size PM Job Address R�ry� 51"2, 'OBJ/ Owner's Name I Gf-Cl « (&tS �sed+LHCAddress 1461 Eu l ion .r- r�sno GA_ Phon6 `� 3�55 6 8 S+Jt CL4� D q�s2o 344 L5 1..__ 34�Pane Address a� icense No.Contractor s " ' TYPE OF WELL/PUMP: NEW WELL I WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION Ll SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS y ❑ Industrial ElOpen Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Qom sticlPrivate l'14 Type of Casing Specifications Fl Pack �7racy 9 �B2oM.Gka-� n Other F1 Delta Depth of Grout Seat G� Type of Grout�t^�+4is f 1 Pubfi� E rr AA t .4b-'Cl f,n YtsaI I Irrigation 7S-3Q._Approx. Depth I I Eastern Surface Seal Installed byRepair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction El Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50'1TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION l I DESTRUCTION i 1 availabe wthin 200 fetiled if public Installation will serve: Residence— Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments 1 PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. A Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS Cl Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ ill be done in accordance with San Joaquin county ordinances, state laws, and I hereby certify that I have prepared this application and that the work w rules 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, I shalt no 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." Qr1 1 r+�;�--�D t V. 't`{ G�'�^e' "'" r Pr I'"t`f I The applicant ust call for all required inspections. Complete drawing on reverse side. q Signed X L Title: a K w..[A- + •�llaCr. PAS-- : 1•`-!•�-1 I FOR DEPARTMENT USE ONLY Application Accepted by Date Area Date Pit or Grout Inspection by Date Final Inspection by Additional Comments: ❑ Stk 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 AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT�NO. INFO E C� + 44 EH 13-21(REV.t/e 51 EH 1428 /