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APPLICATION FOR-PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT O r—!1 1601 E.a�iAZEO ON AVE., STOCKTON, CA , fl U Telephone {2W9 466-6781 r PERMIT EXPIRESI YEAR FROM.DATi ISSUED . (Complete_ ,in Triplicate),: 't.:-t Y,. —,'r• ., .This-app Application is her by made to the San Joaiion is aquin Local Health District for a permit.otoo constructfor,well/purnp and he Rul s and'Regulations of he San Joaquin made in compliance with San Joaquin County Ordinance No.549 for'sewage sf T d.-.�95caPb. ` Local Health District.. ., + „*•- r . y.w 'j41Q grit nc tx; # : -,t , �. PM_ Lot Size— e Job Address t` " - AL2: f Address - — Owneis Name.• t --__ - V tr;k „'Tt l4� Phone -2 00-0 License No. Contr'actor's Name TYPE OF WELL/PUMP: NEW WELL. Ll WELL REPLACEMENT ElDESTRUCTION ❑ 'iSYSTEM'RE.PAIR ❑ OTHER C1 PUMP INSTALLATION F7DISPOSAL FLD. PROP. LINE _ SEWER LINES"" PITSISW k DISTANCE TO NEAREST: SEPTIC TANK ------w--�:--�-�" I OTHER WELL FOUNDATION -• AGRICULTURE, -�-- \ ` '•`- TYPE 4F WELL I PROBLEM AREA gC01VSTRUCTION SPECIFICATIONS INTENDED USE, < —�— Dia. of WeA Casing _ El Industrial �� -- -p_�Ren Bottom Manteca -Dia. of ell FExcavation Specifications 1Type of Casing Cl Domestic/Private ❑ Gravel Pack ©Delia " Depth of Grout Seal Type of Grout. ❑ Public ❑ Other ` i + �{ ❑ Irrigation _ PProx Depth ❑,Eastern Surface Installed by f ! `l "; lH P State Work Done Repair Work Done ❑ Type of Pump.R'gti L� s 6 np + Sealing Material(too,501 ti Well Destruction ❑ WeA Diameter �� .. tiw, ii .e-, Filler Material`(Below 50') ! .Depth TYPE OF SEP71C'INORK NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION ❑ aaailabpeiwiythm 200 feet.) if public sewer is . `� v Installation 1nnA serve: Residence-1— Commer ial � #_ 'T S r Number of li'Ing units: —4-- Number of bedrooms ..I 1 rt Water tattle depth Character of soil to a depth 3 feet: 1 .R , s Type/Mfg CapacltyJ� _ No. Compartmen�s SEPTIC TANK' ype 9 of ,- -{1. v Method�of:Dispogal PKG�TREATMENT PLT. ❑ �' S property Line ` 2r Foundation Distance to nearest:- Well��_ � ,! `hTotallength/size X f LEACHING L1NE No. & Length of lines / moi, Foundation'— Property Line FILTER BED '1�1 ❑ .Distance to'nearest: Well— .1� t t `" Number Depth �' Size 3 �. SEEPAGE PITS r- Line SUMPS ❑ Distance to nearest:' Well F Foundation's Property �I� I ee'l I DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that thel+vork will be done in accordance with San Joaquin county ordinances, state laws, and . rules andregulations of the Sa6'Joaquin Local Health District. cg's work for Home owner iolicensed in such mannerastorbecomfies the following: -,certify hat in the e subject to workman's compensation lawsofCaliforn armante of he Contractor's hiring f ngi or sub cant act ngl signlatu�e employ 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 l tion laws ofCalifornia." must call for all required inspections. Complete drawing on reverse side. The applicant = Title: Date: Signed FO PARTMENT USE ONLY - ' f 1 f-'✓ Area_ .. . Date Application Accepted by r 41-8 S-- ate Final Inspection by Date — Pi 'r Grout Inspection by r y. _ .. Additional Comments: ❑ S 466-6781 ❑ Lodi 369-3621 S.Manteca '823-7104 ❑,Tracy '83"385 Stk., CA 95201 Applicant Return all copies to: Environmental Health permit/Services 1601 E. Hazelton Ave., P.0. Box 2009, CK RECEIVED¢BY DATE PERMIT ND. FEE' AMOUNT DUE AMOUNT REMITTED CASH INFO -+EH 13-24(REV.1018�I9E ; - - - - �- EH 14-26 j .0 . :