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_ ► _ APPLICATION F6A PERMIT SAN JOAQUlN,LOCAL'+HEALTH DISTRICT 1601 E. HAZELT,ON AVE., STO.CKTON, CA Telephone (2091 466-6781 1'Y1 ARTROM PERMIT EXpIRE� DATE ISSUED (Complete in Triplicate) application is to I/ um and the Rules and Regulations of the San Joaquin lication is hereby made to the San Joaquin Local oca He Health 549 for seit a wage or permit No,.1862 for Cwe Idpor install and the work herein described.This I App Joaquin County Ord k made in compliance with San J q F Local Health District, !I I ``•: r a jr/e6 PM City AJ lAb i Lot Size i Job Address a Phone I Address Owner's Name A 25 license No. a�.�Phone Address �5 Contractor WEREPLA,C13 ENT ❑ AESTRUCTIQN ❑ LL 'TYPE OF WELLIPUMP: NEW WELL OTHER PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ PROP, LINE l' SEWER LINES ;__-�- �- DISPOSAL,FLD._�� I DISTANCE TQ NEAREST: SEPTIC TANK � 1PL OTHER-WELL— PITS/SUMPS FOUNDATION -- AGRICULTURE WELL. 0 "£ TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS pia. of Well Casing ! INTENDED USE -- r ` ❑ Open Bottom ❑ Manteca Dia.`of Well Excavation s L' Specifications ❑ Industrial i Tracy IT,yPB,of Casing .. lu(Gravel Pack Type of Grout -- y �1 f]omestic/Private l 1 pelta Depth of:Grout Seal f'1 Public' n Other i4pprox. Depth I I Eastern Surface'Sea1 Installed by, I I I Irrigation H P State Work Done— c Repair Work Done L7 Type of Pump Sealing Material,)top 50') C Well Destruction O Well Diamater —� -- { Depth) Filler Material.lBelow 50'1 TYPE OF SEPTIC-Wo RK: NEW INSTALLATION I a REPAIR/ADDITION.11ti ;DESTRUCTION f I gNailable within,e204 fggtil'ed if public sewer is I , i • E Other — Installation will serve: Residence Commercial _ 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 l 4 - - ' ` Total length/size LEACHING LINE ❑ No. & Length of lines FILTER BEA ❑ Distance to nearest: Well Foundation Property Line I.: Size Number 'SEEPSUMAGE PITS I I Depth i PS ' Ll Distance to nearest: Well Foundation Property Line ` a 'DISPOSAL PONDS ❑ . ; 1 I hereby certify that I have prepared this application and that the-wofkst�rill fdt a rr�accordance wrth San Joaquin county ordinances, state laws, and r ,.rule and',regulations of;the San Joaquin Local Health"Di1trict. ' t "x° "� '` ' I Home ndi reowneor licensed o th agents signature canities the following:r'1 cerpfy1,t+hatcin°the petformancwof the work.for which this permit is issued, I shat}not ,tr't-employ:any,person in such manner'as to become sng signature ubject to workman's Canlpens8tiot%law�s of Ceadili�shali•employ.persona subject to work-Contra ces hiring or tman's ompensa ." ce►t'tiea.the following:"I'certify that in the performance of the work for whic]h r1pe tion.lawskof California." n iThelapplkcant fn t;call for alt required inspections. Com ate drawrng4on reverse Date. Al 9—qo 'F Signed t Title § i i k i QA DEPARTNT USEi ONLY ' ` Date Area Application Accepted by ,n,�' 1 +u a yz�W r Dant q. r Pit or Grout Inspection by j Data�. =rF1 lnfspection by Additional Comments: C�'f 7S Trac r 83!'r63857,.r + El-Stk.•466-6781 r z ❑ Lodi. 369.3621 a Manteca e23.7104 4� Y Applicant Return all copies to: Environmental Health Permit/Servtces}160� E I n Ave P.O.t Bax 2009 Stk., CA 95201 �� 41 FEE AMOUNT DUE AMOUNT REMITTED i . G 'REGEIIlED BV 1 P DATE: PERMIT NO. i INFO +"EN 1124(Rev. i EN 14-x0