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L ; i' APPLICATION EOfbpffR!IAiT�-Acv�.Wo4 11 SAN JOAQUIN LOCAL,HEALTH DISTRICT I 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 y PERMIT EXPIRES 1 YEAR FROM DATE ISSUED } (Complete in Triplicate) , �.,. . . '. �.. ,, a work herein ,.Application is hereby made to the San Joan in Local y Ordinance Nto.District549 for sewage or't to No. 1862 forcwell pump and the Rules and Regulatioijation is pi ns of the Sant Joaquin made in compliance with San Joaquin C .ty Local Health District ` City �� I f' Lot Size) n.. 1 ' PM Job Address _r yYl [J(`1 Address 'r ��. 1 �. - . Jr�C.� Phone Owner's Name k t� License No. Phone 'Cbritracto� Address WELL REPLACEMENT ElDESTRUCTION TYPE OF WELL/PUMP: NEW WELL ❑ SYSTEM REPAIR 11 OTHER ❑ PUMP INSTALLATION ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES -- DISPOSAL -LD. PROP. LINE 1 FOUNDATION AGRICULTURE WELL OTHER WELL— AREA, 5I INTENDED USE TYPE OF WELL PROBLEM AREA. CONSTRUCTION SPECIFICATIONS Dia. of Well Casing I �❑ industrial 11 Open Bottom ❑ Manteca Dia. of Well Excavation Specifications Type of Casing r I D Domestic/Private 11 Gravel Pack ❑ Tracy Depth of Grout Seal Type of Grout '1'3 Public ❑ other ❑ Delta ❑Irrigation ��'pprox. Depth ❑ Eastern Surface Seal Installed by I of Pum H.P. State Work Done Repair Work Done ❑ TyPe p Sealing Material (top 50'1 Wei Destruction C1Well Diameter I Depth f Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION EDREPAIR/ADDITION EDs DESTRUCTION ❑ availavailable io Septic n 200 feet.) jed if public sewer is Ins tallation will serve: Residence J Commercial— Other Number of living units: Number of bedrooms Water table depth b Character of soil to a depth of 3 feet:. Capacity_ o._ - ---- ---- w -- —'NCompartments SEPTIC TANK Type/Mfg_ _,. ...—.. M❑ Te/Mfg � Method of Disposal PKG. TREATMENT PLT. ❑ t Property Line Distance to nearest: Well Foundation P rtY LEACHING LINE C1 No. & Length of lines - Total lengthlsize FILTER BED (7Distance to nearest: Well f - "Foundation r Property line Number SEEPAGE PITS ElDepth t Size ' Foundation Property Line SUMPS ❑ Distance to nearest: i Well . _. , t DISPOSAL PONDS Cl r 0 I hereby certify that I have prepared this application and that the work�ivill be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. ..i i Home owner or licensed agent's signature certifies the following: 'I certlfy.that in the performance of the work for which this permit is issued, l signature shall not on employ certifiesthe fol such manner as to become Ice certify that n the performance of the o-k for which this perm tvis issued,California."of l shall employ p6rrsonslsubjecring rt to workm nt's compensa- tion laws of California." j _ -- The applies '�usi call fo requi d inspections. Complete drawing on reverse side. — _0` x Title: "` Date: i Sign FOR DEP RTMFN USE ONLY. / Date Area pp� Application Accepted by r Pit or Date Final Inspection by Grout Inspection by — Date a 1 � 1 Additional Comments: ❑ Stk 466-6781 C1 Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 5tk., CA 95201 Applicant- Return all ccpies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009,` CK RECEIVED BY DATE PERMIT NO. FEE AMOUNT DUE AMOUNT.REMITTED CASH- ` INFO a a 74X W + EH 13-24(REV,?i-e 5) _ EH 1426