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APPLICATION FOR PERMIT r JOAQU►In�.�.00AL HEALTH DISTRICT SAN � 1601 E. HAZEi i ON AVE., STOCKTON, C Telephone'1209? 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUAED.�}a r,t ; il' >..... y, .1 '(complete in,Triplicate) v u• + and the Rules and Regulations of the San Joaquin o the San Joaquin Local Health District for pe or+No 1662 for wellldpumpstall the work herein described.This application+s Application is hereby made t made in compliance with San Joaquin County Ordinance No.549 for se 9 lr ' Local Health District.`° , i II ILCJt ' / PM ya �I Ci Lot Size ,lob Address� �//}► �A,f � �(I ! r� � �� Phone�3 Address T J, 0 Owner's Name a' �'0 Phone License No. y�' r Address DESTRUCTION 0 t/ VVELL REPLACEMENT ❑ OTHER ❑ NEW WELL ❑ TYPE OF WELL/PUMP: SYSTEM REPAIR ❑ PROP. LINE PUMP INSTALLATION ❑ DISPOSAL FLD. PITS/SUMPS _ SEWER LINES•-�� L FOUNDATION DISTANCE TO NEAREST: AGRICULTURE WELL — OTHER WEL k -TYPE OF WELL PROBL�� CONSTRUCTION SPECIFICATIONS Dia. of Well Casing INTENDED USE p Manteca Dia'of Well Excavation Specifications j ❑ Industrial ❑ Open Bottom Typie of Casing ❑ Gravel Pack ❑Tracy Type of Grout f ❑ Domestic/private ❑ Delta Depth of Grout Seal ❑ Other l ❑ Public ❑ Eastern Surface Seal Installed by i .Approx. Depth i, State-Work-Done y ❑ irrigation H.P.----�- -'�� i T e.of-Pump_Y= t ' Repair Work pone O�.Yp Sealing Material {top 50'1 , PIZ Well Destruction ❑ Well Diameter �l R . ' � r Depth Filler Material IBelow�50'} ermined if public sewer is� --REPAIR7ADDITION ❑` DE- RUCTION ❑ (No septic system p available within 200 feet-Il TYPE OF-SEPTIC-WORK:--NEW'I(VSTAL"L-AT1QN' '1 1 4!f- Commercial, Other Installation will serve: Residence— f D �R- Number edroo s Water table depth F Number of living units: �; Character of soil to a depth of 3 feet: Ij Capacity�� No. Compartments l�Type/Mfg Method of Disposal SEPTIC TANK y r '`• i PKG. TREATMENT PLT. ❑ WellQ , f.'`FoundationQ� Prop_erty Line— -^� Distahce to nearest: ?'�`- / ! Y IJ./) Total lengthlsize� LEACHING LINE L� No. & Length of lines ,� # j r �� Foundation- ��' — Property Line, ,f -� FILTER BED ❑ Distance to nearest: Well — � ; SiF. Number SEEPAGE PITS )DeptSize h ti Property Line , 4 r SUMPS ❑ Distance to nearest: We11e ;- Foundation - i 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, an r not rules and regulations of the San Joaquin Local Health District. =H `1' -work.for Home owner or licensed agent's gm is sil as tobecomesubject to wko kman'scompensation lng: -I certify that in the aws Of Cafi o aria."Contractor i's hiring ngk or sub cont act n 66mermit is issued, I shall signature, employ any person in such b persons subject to workman's compensa certifies the following:"I certify that in the performance of the work for Which this permit is issued,i shall employ Y tion laws of California." ILII � � fi 7 n ust call for equi ed inspections. Complete drawing on revere de. �� 4- �! The appHca j �� i Date: Title: - Signed X fR�; FOR{DEP IA RTMENT USE ONLY Date*14Area } Application Accepted by + f �� Date Date Fi al Inspection by Pit or Grout Inspection by . d Additional Comments: _ d Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823 7104 f ❑ Tracy B3rr6365 Applicant Return all copies to: Environmental Health Permit/Services.,601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 CK# RECEIVED BY f)ATE PERMl7 NO. FEE Afi/IOUIVT DUE AMOUNT pEMITTED Q CASH INFO + EH 13.24(REV.1 i H e) �C> *0 EH 14-2e ..R. yf-•r" _