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APPLICATION FOR PERMIT USAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone 12091 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) t and/or all the work herein described. is madlecntl�ompliaerebynce writh SanoJoaqu nthe SanCounty Ordinalnce No. 549 for sewage orHealth District for a 't to No. 1862 forcwell/pump atnd the Rules and Regulations of tlhe Sanapplication Joaquin Local Health District. �y r7 e e- Rd. City /t e-44_0,V Lot Size y� o1,,-xef PM Job Address /� �r �i9 Y f ' i J 4"A,e X-ree Rc Phone b J A Owner's Name - Address `` r Contractor �/ �/y Address 0047 &�t1 aAl P• License No. yy�941 Phone T © DESTRUCTION ❑ TYPE OF WELLlPUMP: NEW WELL © WELL REPLACEMEN PUMP INSTALLATION ❑ SYSTEM REPAIR D OTHER ❑ i " DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES - DISPOSAL FLD. POOP. LINE -L — DISTANCE AGRICULTURE WELL OTHER WELL PITSISUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS r Dia. of Well Casing ❑ Industrial El Open Bottom ❑ Manteca Dia. of Well Excavation Specifications I ❑ Domestic/Private El Gravel Pack ❑Tracy Type of Casing tl Other -17-Delta., -w Depth-of.Grout-Seal Type of Grout_ - f'1 Public I I Irrigation -Approx. Depth I I Eastern Surface Seal Installed by { W Type of Pum H.P.' A tip= State Work Done Repair Work Done ❑ p Well Destruction ❑ Well Diameter, Sealing.Material (top 50'1 - i Depth Filler Material 1Below 50'I I TYPE OF.SEPTIC WORK: NEW INSTALLATION VT REPAIRlADDITION l 1 DESTRUCTION I I alvailable'w within 200 feet.) is if public sewer Installation will serve: Residence Commercial— Other M06" 3 ;. Number of living units: --L__ Number of bedrooms �. Water table depth Character of soil to a depth of 3 feet:'? /d 1'aI3 Type/Mfg �/4° C 5T &E 4 Capacity E BOO No. Compartments SEPTIC TANK 1 l ."".`"..Method of Disposal, _ PKG. TREATMENT PLT. ❑ iR w i Distance to nearest: Well--5 '!Foundation e' z Property Line_ �� # �e LEACHING LINE ❑ No. & Length of lines T Total length/size` 1 FILTER BED d Distance to nearest: Well •S•'0Foundation O-� Property Line 1 4 i + `" 4 Number SEEPAGE PITS 11 Depth size ' I SUMPS L-1 Distance to nearest: Well Foundation ., Property Line ; DISPOSAL PONDS ❑ 1 I hereby certify that I have prepared thii 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 Diltrict. Home owner or licensed agent's signature certifies.the-following:.."l.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 following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- i tion laws of California." The applicant must call for all required inspections. Complete drawing on re F Signed � { Title: Date: - ,I . OR PARTMENT USE ONLY TM fi Date V�I O^�� Area Application Accepted by ' 3 Date Pit or Grout Inspection by Date Final,lnspection by. t I Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7164 ❑ Tracy 835-6385 { -Applicant- Return all copies to:'Environmental-Health Permit/Services 1601 E. Hazelton Ava.,P.O.'Boz 20o9, Sik., CA 95201. !FEE CKRECEIVED BY DATE PERMITNO. AMOUNT DUE AMOUNT REMITTED CASH -EH 13-24{REV.i i RS) r 6 v 01D EH 1426 f