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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT i 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED {Complete in Triplicate) b made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This application is tion is hereby sewage or No. 1862for well/pump and the Rules and Regulations of the San Joaquin Application fors g Pp ordinance No.549 made in compliance with San Joaquin County Or • C � City PM ,�.., Local Health District.•-_,,�..rr�_• �qy 11 G Lot Size V r Job Address _ Phone ' N Address'. �f Owner's Name l '.� _ 7 E Phone I License'Na. ; f Contractor's Name WELL REPLACE MENT.❑ DESTRUCTION ❑ 4 I TYPE lF WELL/PUMP: NEL WELL ❑ OTHER C1PUMP INSTALLATION ❑ SYSTE M REPAIR ❑ ,r G SEWER LINES �� DISPOSAI�FLD. PROP. LINE D15TANCE TO NEAREST: SEPTICsTANK �—� AGRICULTURE WELL OTHER WELL PITS/SUMPS FOUNDATION _ . INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS f Dia. of Well Casing Bottom ❑ MantecaManeca Dia. of Well Excavation ❑ Open ❑ Industrial , ❑ Tracy Type of Casing ` Specifications El Domestic/Private Q Gravel Pack Depth of Grout Seal""""' "• ` Type of Grout ❑ Public Ll Other E3 Delta l ---Approx. Depth ❑ Eastern Surface Seal Installed,by '�—`�` ❑ Irrigation • State Work Do e Repair Work Done L] Type of Pump �- H.P. *#A* V Sealing Material (top 50'1 I Well Destruction ❑ Well Diameter *f- . er�1 E Depth Filler Material (Below 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITlONtD#ST�RUTIO ❑-� 41111111 aailabpeiwthstem ir 200 feet.) if public sewer is r *WP� :A J IV,, a;^ 1l /L �}4,/Y/c- Installation will serve: Re idence� Commercial_ Other r Number of living units: - IVurllber of bedrooms Water table depth 5 Character of soil to a depth of 3 feet: r7 No. Compartments SEPTIC TANK ❑ Type/Mfg _ �� /Y �T _ Capacity� . Method of Disposal PKG. TREATMENT PLT. ❑ .rI Property Line f t Distance to nearest: Well Foundation Total length/size LEACHING UNE ❑ No. & Length of lines ' Property tine 1 FILTER BED 11 Distance to nearest: Well Foundation d I #a 9 r SEEPAGE PITS ElDepth Size Number ❑ Distance to nearest: Well A# Foundation 3 Property Line SUMPS Al A. DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will be done in accordance witSan Joaquin county ordinances, state laws, and i rules and regulations of the San Joaquin Local Health District. ` 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, l shall not employ any person in such manner as to become subject to workman's compensation laws of California." Contrictor's hiring or sub-contracting signature certifies the following:"I certify that in the Performa a of the work for which this permit is issued,I shall employ persons subject to workman's compense- tion laws of California." r The applicant mus c II a re 'red in ons. Complete drawing on teverse side. �� Date: Title: Signed FOR PARTMENT USE ONLY�, W 497 Date Area Application Accepted by s ` Pit or Grout InspectionbyDate Final inspection by Da Additional Comments: / r ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 Tracy 83546385 zelton Ave., P.O. box 20W, Stk., CA 95201 Applicant' Return all copies to: Environmental Health Permit/Services 1601 E. c : a ! CK 4 FEE AMOUNT DUE AMOUNT REMITTED H RECEIVED BY DATE PERMIT NO. INFO �/r,., _ EH 1324 SREV.10!83} �J 0 O U �S" ��` ^� r £H 14-26