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h I� APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON ON AVE., STOCKTON, CA it Telephone (209) 466-6781 !. PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Applicaon is /or install the work is cation is made nticompliaeieby nce with made SanoJoaqu n county ordinance the San Joaquin Local lNto,549 for sewage or h District for a permit No. 1862 for cwell/pump and the Rules and herein Regulations of tthe San l Joaquin iT Local Health District. i City Lot Size AGS C S PM Job Address ` C- A�tf e Phone �Pq` 77 Owner's Name ress / ` Phone ; Address y,~ License Nos��Q �.� Contractor - l NEW WEL--L�i —WELL-REPLACEMENT- 'PUMP WEL-I-KEPIAGEMENT-O--=�---DESTRUCTION-O-------- -9--TYPE-OF-WELL-tPUMP: OTHER ❑ i r 'PUMP INSTALLATION> SYSTEM REPAIR ❑ i 1PROP. LINE ' �_ SEWER LINDISPOSAL FLD. DISTA'NCE.TO NEAREST: SEPTIC TANK ES PITSISUMPSr�Q FOUNDATION AGRICULTURE WELLl40_ � _Q_& AOTHER WELLP _ INTENDED USE TYPE OF WELL. PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrials Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing T e of Casing �� Specifications omestic/Private ❑ Gravel Pack ❑ Tracy Type r C � ^tel ❑ Other Typ of rout �y I'1 Public � Ll Delta Depth of Grout Seal /��\ I I Irrigation 9S�-Approx. Depth I I Eastern Surface Seal Installed by t t19State Work Done Repair Work'Done ❑ Type of Pump - - H P f Sealing Material (top 50'1 f Well Destruction ❑ Well Diameter 9 ; r Depth Filler Material (Below 501 — F TYPE OF%SEPTIC WORK: NEW INSTALLATION [1 REPAIR/A 1.ITION l-I+,,,DEST. pCTION,l:-1�aNailabptic system rented d public sewer is L Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms Water table depth r � C_baracter of soil to a depth of 3 feet: � Capacity No. Compartments SEPTIC TANK LJType/Mfg t Method of disposal� y PKG. TREATMENT PLT. ❑ S t s' "'�'+ 1♦ ,F Distance to nearest: Well Foundation Property Line + r l r � k LEACHING LINE ❑ No. & Length of'lines'k ' Tata! length/size W iFoundation t Property Line FILTER BED ❑ Distance to nearest:. Well x 1 I I [ SEEPAGE PITS I i Depth N Size _ �-- \Number SUMPS Ll Distance to nearest: Well Foundation Property Line 4 DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work�wiil be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health Dil%lbct. I Home owner or licensed agent's signature certifies the foltowingr"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 followin I certify that in the performance of-the work for which this permit is issued, I shall employ persons subject to workman's compensa- g: ' , tion laws of California." t� The applicant must call for all required inspecti4 mplete drawing on reverse side. Title: _�� >? Date: ' Signed'. ��' '✓`Z FOR DEPARTMENT USE ONLY �f ` r Date C Area Application Accepted by ' Date Final Inspection by Date Pit or Grout Inspection by Additional-Comments:-- ❑ Stk _466-6781 ❑ Lodi 3693621 0 Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave.,P.O. Box 2009, Stk., CA 95201 le E i FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE jPERMIT'NO. CASH EH13-24IREVt/H51 INFO �� _ ` � CSI ^ � �k�z 'i f