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. a i� APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL ION�AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR'FROM DATE ISSUED".: (Corriplete in Triplicate)mt to cation is „. , Application is hereby made to the SanJoaquin ordHealth inance No.D549 for sewage or 1No.istrict for a per1862 forcwell apump and the Rules and/or install the work 'Regulations of the San n described.Th s l Joaquin County made in compliance with San Joaquin dina Local Health District. - - n City h Lot Size PM Job Address _ Phone Address r� Owner's.Name 47t £7, L'J _ Phone Y ' License No,�,�t Address C'ontractor -DESTRl7CTION-❑-_N SYSTEM WELL' -- -WELL REPLACEMENT"❑ ;j` N ---TYPE OF-WELL-/Pt'1MP:"--"' �� SYSTEM REPAIR ❑ OTHER El 1 PUMP INSTALLATION ElPROP. LINE SEWER LINES �.� DI3POSAL FLD- DISTANCE TO NEAREST: SEPTIC TANK 01-HER WELL PITSISUMPS 1 FOUNDATION AGRICULTURE WELL I INTENDED USE TYPE OF PROBLEM AREA CONSTRUCTION SPEC FkCAT10N5 Dia. of Well Casing l Dia. of Well Excavatior> ❑ Industrial Ll Open Bottom ❑ Manteca i Specifications ❑ Tracy Type of Casing ❑ Domestic/Private ❑ Gravel Pack Type of Grout -�tDeltar y� ,;�;,`"��Depth of Grout Seal ` i El Public other 15urface Seal lnstalled y F1 Irrigation —11-Approx. Depth Eastern State Work Done i 1, ..i H',-P. Repair Work Done.JC] Type of Pump f Sealing Material )top 50'} ' ` Well Destruction, ❑ Well Diameter �� Filler Material (Below 50'1 Depth available within 200 feet.) 4 i TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION ❑ (No septic system permitted if public sewer is l' Installation will serve: Residence_�4_ Commercial_ Other } Number of living units: Number of be - Water table depth r Character of soil to a dep4 of 3 feet: (n Capacity�oo1�G'4 L No. Compartments SEPTIC TANK Ig Type/Mfg Method of Disposal PKG. TREATMENT PLT. ❑ Pro a Line; -,- ._ Well Foundation c1�fJ P 'ty Distance to nearest: Tdta~f - f.Iength/size LEACHING LINE ❑ No. & Length of lines ! 1 Foundation i' �rqp r�Vjjne y FILTER BED ; Distance to nearest: Well r j. Number Size SEEPAGE PITS ❑' Depth ert " Pro ine I i Foundation Property-L- 4 SUMPS ❑ Distance to nearest: Well .J � t t s. DISPOSAL PONDS ❑ application and that the work w111 be done in.,accordance witli,San Joaquin county ordinances, state laws, and I hereby certify that 1 have prepared this app --.,� � I _.,,_..__. , rules and regulations of the San Joaquin Local Health District. Home owner or licensed agent's signature certifies the following: "1 certify that in the performance of the work for which this permit o issued, I shall not ' employ any person in such riianner as theeC me subject l the to rk k foan'swh ch this permit s issued, tion laws of fl shall employ perrsonsornia." Contractor'slsubjectring �t workman'sne mpensa certifies the following:"I:certify that m pe. - ( ; I s tion fainrs of.California." �� si- ; r'• The applicant must tail for" quir inspections.'Complete drawing on reverse side. {.. Date: fI 1/ tF6� 1 ai Title: _Signed } ;...� ; FOR DEPARTMENT USE ONLY Date 1 (.� Area Application Accepted by j ; S .. i1' .M Date ' Firti81 t� Gate `" 1 spection by G i Pit or Grout Inspection by,{ ,_ ' Additional Comments: II `• '�'• �T e ant�8v .83r.6385_ _..~ Trac ❑ Stk 466-6781 CCLodi9-3621 - ii '�`=4 ✓ '--� �- .CA-95201 Applicant- Return ali copieffs to: Environmental Health PermitlSerwces-1601.E. Hazeltarl_Ave..-E..O_Bo 2009,.- tk - PERMIT'NO. DU AMr'-,UNT REMITTED CK# RECEIVED BY DATE �. AMOUNT DUE CASH INFO f +EH 13-24(REV.1/8 5) r b/Zto/�S mss_ �t o EH 14-26