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r � , APPLICATION FOR PERMIT > SAN JOAQUIN'LOCAL HEALTH DISTRICT . . *.�c . k 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM-DATE ISSUED , } 1,--!'w1, • , ,.ter.: - �, ., ; (Complete in,Triplicate). v-10,,t . . W;k1, cation is Application is hence wSanJoaquin County Ordinance made othe San Joaquin Local Health District549 permit cd .This for sewage or No. 1862 forwell/pump and the Rol s and r install the work IR Regulations of No. he Sanl Joaquin l•, made in compliance L Local Health District. City ,t^ Lot Size PM k Job Address Address 1930 / "€ • ., f ��' } 'L � G1�El C .t ' =*Phone U _ :- Owner's Name- Phone Contract " _Q Address < < � - a NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ f TYPE'OF IIVELL'/PUMP:' SYSTEM REPAIR 11O7HER Q 1 a z fl p t (J NSTALLATION ❑ I_ SEWER LINES DISPOSAL FLD. LINE __ Y PROP. DISTANCE TO.-NEAREST: SEPTIC_ TANK. PITS/SUMPS i AGRICULTURE WELL OTHER WELD , 4 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS pia. of Well Casing k ❑ Industrial EJ Open Bottom ❑ Manteca Dia. of Wall Excavation Specifications r Type of Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Depth of Grout Seal Type of Grout ❑ Public [3.Other ❑ Delta [2 Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by x --T----H.p- State Work Dane �Repair WN rk Done O Type of Pump ESealing Material (top 50'i Well Destruction ❑ Wel! Diameter ler Material (Below 50'1 ' e:, k Depth " i TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ rEPAIR DDITION DESTRUCTION ❑ (No am w thsn 200 fee_titted if publ-4 i�c sewer is ` . Installation will serve: Residence Commercial— Other T O Number of living units: Number edroo s [� " ifyl Water table depth Character of soil to a depth of 3 feet: No. Compartments SEPTIC TANK ❑ Type/Mfg 1 j Capacity Method of Disposal ; PKG. TREATMENT PLT. ❑ x Property Line Distance to nearest: Well Foundation i F _/ - Total length/size 1 LEACHING LINE i�J No. & Length of,lines•= a t - t l FILTER BED ❑ Distance to nearest: Well Sl— Foundation / _- Property Ling Size Number SEEPAGE PITS ❑ Depth _ "r i 1 "Foundat€on Property Line *�' , SUMPS J - ❑ Distance to nearest: Well - ; _ r r k DISPOSAL PONDS ❑ l hereby certify that I have prepared this application and that the work will be done in accordance with'San Joaq in couhty ordinates, state laws, and rules and regulations of the San Joaquin Local.Health District. 1 rtify that in the performance of.the work for which this permit is issued, I shall not Home owner or licensed agent's signature oertifis'the fallowing: "I ce subject to workman's compensation laws of California."Contractors hiring or sub-contracting signature employ any person in such manner as to become certifies the following: "I certify that in the performance of the work for which this permit is issued,!shall employ persons subject to w1-7 kman's compensa tion laws of California. l r' ( . The appllca must call f al required inspect ons. Completeti-&aWing on reverse 'de. i lit c Date: Signed Title: ^� 1 _ FOR DEPARTMENT�USE-ONLX _. - Date 31rea A Application Accepted by 'J "f r f s Final Inspection by_ _ Date a �� Pit or Grout Inspection byYDate _ , . 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 2008, Stk., CA 95201 FEE CK RECEIVED BY DATE PERMIT"NO, INFO AMOUNT DUE AMOUNT REMITTED CASH + EH 13-241REV.1/s 5) ,� S —16-7 EH 1428 V --