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APPLICATION FOR PERMIT SAN JOAQUIIV LOCAL HEALTH DISTRICT '2' 3' 1 1601.E)H2i Z.E' TO'N�AVEE, STOCKTON, CA � I Telephone (209) 466-6781 e, PERMIT EXPIRES 1'YEAR FROM DATE ISSUED (Complete in Triplicate) ntion is rk herein de, V Application is hereby made to the San Joaquin Local Health District for sewage or permitto 1862 forcwelUpuor install the mp and the Rtes and R�e�a^�� San Joaquin r made in compliance with San Joaquin Couunty Ordinance Na Local Health District. r ' Cit t Size PM Job Address S 0 MLf Address VV Phone Owner's Name { License No. Phone ContrAO T.r Address TYPE OF WELLlPUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ ALSYSTEM REPAIR ❑ OTHER ❑ y PUMP INSTALLATION ❑ I SEWER LINES DISPOSAL FLD. PROP. LINE DISTANCE TO NEAREST: SEPTIC TANK PITS/SUMPS L FOUNDATION AG WELL QTHER 'WELL, .+ 4�� t INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPLCIFICAtiFIONS='�A\. \ ❑ Open Bottom El Manteca Dia. of Well Excavation t�* Dia. of Well Casing �\ ❑ Industrial r % ,� �'`r Specifications a .;, �•� r Type of Casing ❑,Domesu (Private ❑ Gravel Pack ❑ Tracy 1 Oelta Depth of Grout Seal i ! TypeFof Grout — [I Public � � n Other M� t _ Approx. Depth l I Ea tern Surfac Seal Installed by r I I Irrigation / State Work Done Repair Work Dane I,, Type of Pump �'L�' H.P. 1 !. _ �Q_.�Wel1 Diameter r Sea ling-MateriaL.It6p.50'1 Well Destruction, 1 :1DeptFi'�`1 j 4�` ` Filler Material (Below 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION-0- REPAIRIAOI)ITION 11-'-DESTRUCTION l lyavailable;witthintiC s e e-200 feet.) it public sewer is a E wr i m pe Installation will serve: Residence Commercial_ Other ` Number of living units: Number of bedrooms Water table depth Character of soil to a depth of 3 feet: No. Compartments SEPTIC TANK ❑ Type/Mfg Capacity Method of Disposal PKG. TREATMENT PLT. Distance to nearest: Well Foundation Property Line � I f ngth of lines Total length/size G' A LEACHINLINE ❑ No. & Ler` FILTER BED ❑ Distance to nearest: Well Foundation Property Line I M Number SEEPAGE > ITS 1 1 Depth I Size SUMPS L-1 Distance,to nearest: Well Foundation Property Line DISPOSALWONDS Q 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 regulatio t e Joaquin Local Health Di§trict. Home own,�r o tensed agent's ignature certifies the fallowing: "I certify that in the performance of the work for which this permit is issued, I shall not employ any rson in such mann as to become subjec orkman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies t any, "I certify at in the rmanc of a work for which this permit is issued,I shall employ persons subject to workman's compensa tion law of California." The ap licant must c 11 f all quire t mplet �rawing on side Title: Dater Signed '+ F'bR DEPARTMENT USE ONLY Date Area Application Accepted b Date�� Final Inspection by Date Pit or Grout Inspection by Additional Comments: x ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ 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 o FEE CK RECEIVED BY DATE PER AFT NO. AMOUNT DUE AMOUNT,'REMITTEO CASH INFO ,.. 3 � I�� %_A 20� .,EH 13-241REV:i/A5) EH 14-26 - � w