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APPLICATION FOR PERMIT DISTRICT SAN JOAQUIN LOCAL HEALTH I D 1601 E. HAZE TON AVE., STOCKTON, CA Telephone (209) 466-6781 SEP 17 Ml PERMIT EXPIRES 1-YEAR FROM DATE 'SSF-AR F?UikAPiENTAL HEALTH (Complete in Triplicate) PERMIT/SERVICES Application is hereby made to the San Joaquin Local Health Districtor fa permit to construct and/or install the work herein described. This application is ge or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin made in compliance with San Joaquin County Ordinance No. 549 for sewa Local Health District. City Lot Size PM Job Address FA — 's Phone Owner's Name Address ft Address AL A41�- License N1.90 —Phone Contractor TYPE OF WELL/PU P: EW WELL L1 WELL REPLACEMENT 0 DESTRUCTION 0 N SYSTEM REPAIR X OTHER El 'PUMP-INSTALLATION U /DISPOSAL FLD.— PROP. LINE DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT-SI-SUMPS - —FOUNDA-T-16N -1 AGRIC-UL-TURE-WEL-L— ��THER-WELL� INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 0 Open Bottom El Manteca Dia. of well Excavation Dia. of Well Casing E Industrial Type of Casing Specifications El D=ptic/Pril-0- Gravel-Pack- 'Tracy Type of Grout n Other I F1 Delta Depth of Grout Seal [-I Public ❑ Approk surface S"I Installed by Irrigation Depth I I Eastern State Work one Repair Work Done 0 Type of Pump H�P.. Well Destruction El Well Diameter _____4(l Sealing Material Itop 501 Depth -30 Filler Material (Below 501 RK-' NEW INSTALLATION L-I REPAIRIADDITION 1. 1 DESTRUCTION I I (No septic systernpermitted if public sewe is TYPE OF SEPTIC W available withi�n 200 feet.) installation will serve: Residence Commercial— Other Number of living units: Number of bedrooms Water table,de4th I Character of soil to a depth of 3 feet: Capacity No. Compartments SEPTIC TANK D Type/Mfg ,. Method of Disposal PKG. TREATMENT PLT. 0 Distance to nearest: Well Foundation Property Line 0 No. & Length of lines .,-�Total length/size LEACHING LINE I FILTER BED und . Property Line El Distance to nearest: Wellc�— Fo6tion— SEEPAGE PITS I I Depth I Size Number SUMPS I to nearest: Well Foundation Property Line SUMPS Distance DISPOSAL PONDS Cl ordinances, state laws, and t I hereby certify that I have prepared this application,anidhat the work will be done in accordance with San Joaquin county rules and regulations of the San Joaquin Local.1-16alth D%itrict. ies the following: "I certify that in the performance of the work for which this permit is issued, I shall not Home owner or licensed agent's signature cerj�fs of California." Contractor's hiring or'sub-contracting signature employ any perso .In such manner as to'l�ecome subject to workman's compensation law o '�h performance of a certify manner "o -I certify thal performance of the work for which this permit is issued, I shall employ persons subject to workman's c mpensa- certifies the follo i c tion laws o A t all 0 e r ui,. t. d tions mp!ets drawing o re se side.. a t call for all r uire ctions. Th appfic aXt ' Date: Signed X Title: TM -Y FOR DEPA+RTMT USE ONLY— Date f7r Are Application Accepted by Date Pit or Grout Inspection by --------L Date Final Inspe6:tion by Additional Comments: — r LJ Stk 466-6781 0 Lodi 369-3621 13 Manteca 823-7104 t -0 Tracy -835-6385---' Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave- P.O. Box 2009, Stk., CA 952011 CK MN11i RE��,IV�D BY DATE PERMIT" 0. FEE AMOUNT DUE AMOUNT REMIT-TED CASH INFO *.Eli 13-24 IflEV.1/1851 S EH 14-28