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n APPLICATION FOR PERMIT SAN JOAQUI.N LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED' { (Complete in'Triplicate) e or.No. 1862 for well/pump and the Ryles and Regulations of the San Joaquin Application is hereby made to the San Joaquin Local Health District sewag permit to construct and/or install the work herein described.This application is lance with San Joaquin County Ordinance made in compliance -Local Health District. nPM 1. � City Lot Size Job Address 4 � one -Address Owner's Nam y License No. Phone i a/] Address - ��„' "'" `— Contractor WELL REPLACEMENT ❑ D ❑ ES TYPE OF WELL/PUMP: NEW WELL ❑ OTHER SYSTEM REPAIR ❑ PUMP INSTALLATION ❑ DISPOSAL FLD. PROP. LINE SEWER LINES ._��— DI ?ITS/SUMPS STANCE TO NEAREST: SEPTIC TANK AGRICULTURE WELL__- OTHER WELL _ FOUNDATION _-- --- — k PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing INTENDED USE TYPE OF WELL ❑ Open Bottom . ❑ Manteca. Dia. of WeILExcavation Specifications ❑ Industrial - s -- Type of Casing ❑ Gravel Pack ❑ Tracy�%�_ ¢. Type of Grout (� Domestic/Private r Depth of Grout Seal ❑ Other ❑ Delta ❑ Public Surface Seai.lnstalled by ❑ Irrigation Type�of 4pproxPum.p Depth EI Eastern State Work Done H.P. Jc,"`. .. v Repair Work Done —Sea ling Material (top-50'1 I Well Destruction Ll Well Diameter _ - Depth Filler Material 1(Below 50'1 rmitted if public sewer is available within 200 feet.) TYPE OF SEPTIC WORK: NEW INSTALLATION AIR/ADDITION ❑ DESTRUCTION ❑ ava(Noilable septic system Commercial— Other------ installation will serve: Residence—1 , CM Number of living units: Number of bedrooms Water table depth Character of soil tc a depth of 3 f ,. Capacity_ No. Compartments TN SEPTIC TANK ❑ Type/ g f Method of Disposal PKC. TREATMENT PLT. ❑ 4` � Foundation Property Line�- Distance to nearest: Well�� Total length/size LEACHING LINE ❑ No. & Length ofdines Property Line Foundation------on � FILTER BED ❑ Distance to nearest. Well l "Size .. t Number SEEPAGE PITS ❑ Depthl'f Property Line SUMPS ED] Distance to nearest: Well Foundation DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will'be done in accordance with San Joaquin county ordinances, state laws, an this permit is rules and regulations of the San Joaquin Local Health District. ity that in the g work for Home owner or licensed agent's signature cenme subject Ito w'orkman'srtcompensation laws performance of Californian"Contractor's hiring orr sub-cont actingls gnatushall �e employ any person in such manner as to bac arsons subject to workman's compensa certifies the following:"I certify that in the pe h ormance of the work for which this permit is issued,1 shall employ p tion laws of California." e t The applicant must call f 11 required inspections. Complete drawing on re se side. yy Date: Title: _ Signed X lli 1 .�'C•f�J �-= p . �...r �,��,�= -•— FO EPARTMEIVT 13SE ONLY � Date Area Application Accepted by Date/11_�_ - Pit or Grout Inspection by Date�� Final Inspection by Additional Comments: ❑ Manteca 82.3-7104 ❑ Tracy 8354M Stk., CA 95201 k ❑ Stk 466-6781 ❑ Lodi 3fi9 3621 Applicant- Return all copies to: Environmental Health'Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, ! ` 11 FEE AMOUNT 1DUE AMOUNT REMITTED GASH RECEIVED BY ' DATE PERMIT`NO. � INFO � �- !Y-�y ff�-j 37 +EH13-24IREy.t/s51 EK 1426