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A. APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE-, STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 11'YEAR FROM DATE ISSUED (Complete in Tri licate) j Application is hereby made to the San Joaqu L 1 Heal istrict perms o c and r' 11 e k h es ed. This application is made in compliance with San Joaquin Cour 1 or o. 18 o a t e R les d R tions�f the San Joaquin Local Health District- C Job Address ^ 2 City -+ t Size ___ PM f� � Owner's Name dress / �" Phone Contractor/ ' r Address 4_jl� AE "" "r'�" License No. V Phone TYPE OF WELL/PUMP: NEW WELL.❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ -T PUMP-INSTALLATION ❑ SYSTE REPAIR ❑ OTHER ❑ , DISTANCE TO NEAREST: SEPTIC TANK SEWER L ES"� DISPOSAL FLD. PROP. LINE 1 FOUNDATION " AGRiCUL RE ELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA C NSTRUCTION SPECIFICATIONS a LI industrial El Open Bottom ❑ Manteca ia. of Well Excavation Dia. of Well Casing r { O Domestic/Private # C1 Gravel Pack ❑ Tracy Type of Casing Specifications ? y 11 Public f1 Other I-1 Delta Depth of Grout Seal Type of Grout I lrrigation r _Approx. Depth 1 1 Eastern urface Seal Installed by Repair W06 Done Ll 'type of Pump — H State Work Done _ L f Well Destruction C1 .i Weil Diameter ealing Material ltop 50') ' DepthFiller Material 1 tl 50') TYPE OF SEPTIC WORK: NEW INSTAL T N I } EPAI �,DD_ITI} DE TRUOL,C N I INo septic system permitted if public sewer is ��-�Y 14 avai le wit 200 feet.) n Installation will serve: 1 Residence _ ommercial Other r1` Number of living units: NMber of roams Character of soil to a depth of 3 feet: .f Water table depth i SEPTIC TANK ❑ Typq/Mfg _ pacity No._Compartments, PKG- TREATMENT PLT. ❑ Method of Disposal r—"r Distance to nearest: Well - Foundation Property Line LEACHING LINE ❑ No. & Length of lin Total length/size__._ ' ) FILTER BED f❑ Distance to nearest• oundation Property Line SEEPAGE PITS :i I Depth 1 Size _ N mbar SUMPS rLl Distance to nearest: Well Foundation Ju-_ Property Line DISPOSAL PONDS ❑ r I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health Di§trict. 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 fopowing: "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 taws of California." The applicant us1 call far aI uired'i" pections, C plate drawing ori reverse side. Signed X h 1 �l Title: 6 Date: OR DEPPfRTMENT USE ONLY _ Application Accepted by r ;?v r.. Date Area Pit or Grout Inspection y t�- Date Final Inspectio by Additional Comments: Ci Stk°, 466-67B1 t ElLodi 3694N111, ❑ Manteca 623-7104 ❑Tracy 8356385 I ' Applicant - Return all copies to:.Environmantal Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201CK FEE INFO AMOUNT DUE AMOUNT REMITTED CA RECEIVED BY OATE PERMIT NOY +". 15/1/ //�� y+EH 1a-21 tRfV.1in51 o� qEH 1126 "� K•