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APPLICATION, FOR PERMIT 3 0 SAN JOAQUIN LOCAL HEALTH DISTRICT , 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 _PERMIT_ EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) rk herein . This cation is made Application ipbe iee wmaith e o the San Countyr0 ordinance No.Sag for sewage or ealth District for a permit 1962 for cwei pumt and/or p and the Rstall the u es and Regulations of the San r Joaquin Local Health District. J� ,6 L1 City - Lot Size—.. — PM — Job Address _SL-- `—{ p Phone Address Owner's Name __ �" "_ 1• t� ,.I Contractor WENE] s License No. M Phone TYPE Of WEI L,PUM NErV WELL REPLACEME 1 DESTRUCTION C-! PUMP INSTALLATION 1`1 SYSTEM REPAIR I. OTHER C1 SEWER LINES _ -..._ DISPOSAL FLO._.— PROP. LINE _— DISTANCE TO NEAREST: SEPTIC TANK _' , OTHER WELL PITS/SUMPS _. -- -. AGRICULTURE WELL FOUNDATION _—�_- -- — INTENDEDUSE TYPE Of WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS _ - Dia. of Well Casing - ❑Industrial L.1 Open Bottom ❑ Manteca Dia. of Well Excavation_ — Type of Casin _ Specifications O Domestic/Private I Gravel Pack G Tracy yp `J Type of Grout ._ M Public f i Other i-I Delta Depth of Grout Seal yp — 1 1 Irrigation —.Approx. Depth I ! Eastern Surface Seal installed by - -- _ Repair Work Done L' Type of Pump _ 11.P• State Work Done-- `I Well Destruction U Well Diameter _ Sealing Material (top 50"I --- - — Depth Filler Material 116eloviAXI - -- 1 OD i TYPE OF SEPTIC WORK: NEW INSTAL-CATION I I REPAIR!ADDITION I -DESTRUCTION I (No septic 2W feet.) rt public sewer is Installation will serve: Residence— Commercial _ Other ` Number of living units: -,V- Number of bedrooms _ - IeA > Water table depth_ Character of soil to a depth of 3 feet: SEPTIC TANK ❑ TyperMfg — Capacity No. Compartments \PKG. TREATMENT PLT. i7 I Method o1 Disposal Distance to nearest: Well Foundation I ..-_ Property line t I EACHING_LINE [ No. 8 Length of lines -_ Total length/size F BED L! Distance to nearest: Well Foundation _7 Property Line AGE I.I Depth Size-- _ Number SUMPS -1 Distance to nearest: Well J Foundat on Q 8 1 ProWrtY Line DISPOSAL PONDS 17 I Ind that the work will be done in accordance with San Joaquin county ordinances, state laws, and I hereby certify that I have prepared this application a 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 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-" The applicant I c r req inspections. Co ate drawing On re 5 side. Signed X Title: Date: - F EPARTMENT USE ONLY it Date 2 _ Area . Application Accepted by !' ; Pit or Grout Inspection by _ h Date Final Inspection by_� ��` — Date_ I ,f Additional Comments:- a ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 El Tracy 835 6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.0- Box 2009, Sik-, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED 8Y DATE p� PEHMIT NO. EH 13-24(REV.rr n�i �>D - � `4 gel EH ICM