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APPLICATION FOR PERMIT f = SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE i ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) application is rice No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Application is hereby made to the San Joaquin rd nal Health District for a permit to construct and/or install the work herein described. This p made in compliance with San Joaquin County Local Health District. .� C' ity Lot Size Job Address 4' Phone ddress Owner's Name > Phone License No. �(/fS Address DESTRUCTIO Contractor WELL REPLACEMENT ❑ N W WELL L-1-1 7. OTHER ❑ TYPE DF WELLIPUMP: SYSTEM REPAIR ❑ 4 PUMP INSTALLATION El DISPOSAL FLD. PROP, LINE DISTANCE TO NEAREST.: SEPTIC TANK"'4��, — . SEWER LINES ��— PITS/SUMPS � AGRICULTURE WELL OTHER WELL I FOUNDATION �� INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS pia. of Well Casing ❑ Open Bottom ❑ Manteca Dia,. of Well Excavation ❑ Industrial Specifications I ❑ Gravel Pack ❑ Tracy Type of Casing E ❑ Domestic/Private Depth of Grout Seal Type of Grout n Other C7 Delia i`l Publick Surface Seal Installed by f I Irrigation Approx. Depth l I Eastern State Work Done " r Typo of Pump fit— H P' f r Repair Work Done yp Sealing Material [ __ Zo Well Destruction Well Diameter t1 Depth— f1� Filler Material {Below ermined if public sewer is i available within 200 feet.) = TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 flEPAIfllADDITIO� l } DESTRUCTION l I o septic system f Installation will serve: Residence #� Commercial— Other k i ' a E Number of bedrooms \ V � Number of living units: \ Water table depth Character of`wl toga depth of 3'feet: t,Capacity�� No. Compartments SEPTIC TAMC d ❑ Type/Mfg Method of Disposal PKG:-JREATMENT PLT. ❑ Foundation Property Line��-- r Distance to nearest: � + Well 1, Total length/size LEACHING LINE ❑ x Na. & Length of lines; _ Foundation Property tine FILTER BED' ❑ s Distance to nearest: .' Weft= - + e 1 Number SEEPAGE PITS I } r Depth - Sixe i '•`* Foundation Property Line SUMPS # Ll Distance to nearest: F Well 3 DISPOSAL PONDS ❑ { Thereby certify that l have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, an 'rules and regulations of the San Joaquin Local Health District. shall not Home owner or licensed agent's marine gasature certifies the to become subject Ito workman'slowing: "I rtcompensaify that intion lawsoof Califormance ornia." Contractor's hung'or sub-contracting lsignatu e emp y y Pe 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 p I tion laws of California." ' The appliO3 cant us 11 requir n s. Complete drawing on reverse side. 91 Title: - Date: Sighed X � 1 � FOR DEPARTMENT USE ONLY ` Dab:i — Area— 1 � Application Accepted by - Pit or Grout Inspection byDate Final Inspection Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca a23-7104 ❑ Tracy 835-M5 ironmental Health Permit/Services 1601 E. Hazelton Ave., P.O. BOX 2 Applicant'- Return all copies to: Env009, Stk., CA 95201 CK RECEIVED BY DATE PERMIT NO. FEE AMOUNT DUE AMOUNT REMITTED CASH INFO +,EH 13-24 MEV.1/k 51 EH 14-26 i