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APPLICATION FOR PERMIT � SAN JOAQUIN LOCAL HEALTH DISTRICT I h 1601 E. HAZELiON AVE., STOCKTON, CA f7} Telephone (209) 466-6781 J PERMIT EXPIRES 1 YEAR FROM DATE ISSUED t (Complete in Triplicate)District for a application is /or install the Application is hereby made to the aCouqul LocalHealth nce No.549 for sewage or permit 1862 for well/dpump and the R n send hereinrk described. of he San Joaquin made in compliance with San Joaquin Local Health District. r I 1S 4L Lot Size PM C it Job Address Phone �9�.7� 3 / 1 Owner's Name UAddress o P License No. Phone Contractor r Address WELL REPLACEMENT ❑ DESTRUCTION ❑ TYPE OF WELL/PUMP: NEW WELL 11OTHER ❑ PUMP INSTALLATION L] DISPOSAL REPAIR C1 DISPOSAL FLD. PROP. LINE ��-- i` DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PITSISUMPS AGRICULTURE WELL OTHER WELL FOUNDATION STRUCTION SPECIFICATIONS INTENDED USE TYPE OF WELL PROBLEM AREA CON WDia of Well Casing L) Open OBottom ❑ Manteca Dia. of Well Excavation Specifications [I Industrial Tracy Type of Casing industrial Domestic/Private ❑ Gravel Pack Type of Grout ❑ ❑ Other 171 Delta Depth of Grout Seat n Public surface Seal Installed by I I irrigation �_.Approx: Depth f I Eastern H,P. State Work Done Repair Work Done ❑ Type of Pump Sealing Material (top 50'1 Well Destruction L3 Well Diameter — -- Depth I Filler Material IBelow 501 avail NSTALLable within 200 feet-I TYPEOt= SEPTIC WOflK: NEW Installation will serve: Residence It ATION l 1 REPAIfllADD171ON l i DESTRUCTION (No septic system permitted if public sewer is Commercial— Others � , f Number of living units: Number of bedrooms Water table depth Character of soil to a depth of 3 feet: No. Compartments r' Capacity— SEPTIC apacity —SEPTIC TANK ❑ TypelMfg Method of Disposal - PKG. TREATMENT PLT- ❑ Foundation Property Line Distance to nearest: Well Total length/size LEACHING LINE t ❑ No. & Length of Tines Foundation Property Line to nearest: Well FILTER BED ❑ Distance —� 1 1 Size Number SEEPAGE PITS I I Depth Property Line SUMPS i ❑ Distance to nearest: Well Foundation " 1 DISPOSAL PONOS ❑ wall be done in accordance with San Joaquin county ordinances, state laws, and Thereby certify that f have prepared this application and that the work rules and regulations of the San Joaquin Local Health District, I Nome 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 signature she not employ any person;n such manner as to become subject to workman's compensation laws of California." Contrace6sonsrsub ctring or so workman�scompensa- I certifies the following: ''I certify that in the performance of the work for which this permit is issued, I shall employ p 1 �' tion laws orn;a." I st all for all r qui vs ions, ete drawing on reverse side. The ap f �7 6 Title: �r11111,11 0�11 Rate: Signed X ` FOR DEPARTMENT USE ONLY Date Area Application Accepted by pate k Date_�� Final Inspection by Pit or Grout Inspection Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369 3621 L] Manteca 823-7104 ❑ Tracy 835 6385 ox 2009, Stk., CA 95201 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. B RECEIVED 8Y DATE PERMIT'NO. FEE AMOUNT DUE AMOUNT REMITTED CASH r +.EH 13-24 IREV.I/K!5) EH 14-26