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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL ON AVE., STOCKTON, CA i Telephone (209) 466-6781. l PERMIT EXPIRES 1'YEAR FROM DATE ISSUED (Complete in Triplicate) I.. 549 for sewage r No. 1862 for we111pump and the Rules and Regulations of the San Joaquin i ' tion is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described-This application`is Applica �I made in compliance with San Joaquin County Ordinance N Local Health District. Lot SizePM _ City Job Address Phone � l.aL� 1 i S(-1Z-• Address Owner's Name I � I 1� /� L� tr�a License No�y�� ' Phone ..f] (..fin j� Address 5� DES Contractor WELL REP AGEMENT CITRUCTION ❑ NEW WELL ❑ OTHER 0 TYPE OF WELL/PUMP:. SYSTEM REPAIR C1 PUMP INSTALLATION ❑ DISPOSAL FLD. PROP. LINE SEWER LINES �� PITS/SUMPS DISTANCE TO NEAREST: SEPTIC TANK —�— AGRICULTURE WELL OTHER WELT FOUNDATION --- INTENDED USE TYPE OF:WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia of Well Casing ❑ Open Bottom""""`""❑`Manteca, Dia. of Well Excavation ' ❑ Industrial Specifications ❑ Tracy Type of Casing ❑ Domestic/Private ❑ Gravel Pack Depth of Grout Seal Type of Grout -- ❑ Other Cl Delta � - F I Public „I Surface Seal Installed by App�ox. Depth i I Eastern +. P State Work Done Repair Work Done ❑ Type of Pump r Sealing Material (top 50'1 Well Destruction ❑ Well Diameter —�-- , i Depth Filler Material (Below 50'I ailable within 200 feet.) f TYPE OF SEPTIC WORK:- NEW INSTALLATION is REPAIRIADDITIDN l I DESTRUCTION i No septicsystempermitted if public sewer is Installation will server Residence III Commercial' Other��--- Number of living units: Number of bedrooms a Water table depth Character of Soil to a depth of 3 feet: t i Capacity� -- � Na. Compartments SEPTIC TANK' C3Mf Typelg i Method of Disposal r PKG. TREATMENT PLT. ❑ Foundation Property Line Distance to nearest: Well 1 I ! ' Total lengthtsize ❑ No. & Length of lines LEACHING LINE t Foundation Property Line�� t ` FILTER BED ❑ Distance to nearest: Well Size Number SEEPAGE PITS 11 Depth property Linef ❑ Distance to nearest: Well Foundation p SUMPS t DISPOSAL PONDS ❑ application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and I I hereby certify that I have prepared this app rules and regulations of the San Joaquin Local Health District. that in the gwork for Home owner or licensedc�g�an g gas to become subject,to workmanIsrtcompensation lifyawsoof California."Contractor'srhiringr or sub contracting signatus permit is issued, I shall re employ any person inspersons subject to workman's compensa- certifies the following:"I certify that in the performance of the work for which this permit is issued, I shall employ p 1 tion laws of California." The applicant mu t call for all re ed inspections. Complete drawing on reverse side. 2ar►?`�!� Date: s �� l Title: Signed X f� FOR DEPARTMENT USE ONLY p Date �a Area Application Accepted by Date 2L_Z _ I< Date Final Inspection by Pit or Grout Inspection by // J♦ '� Additional Comments: Manteca 823 7104 ❑ Tracy 836-6385 ❑ Stk 466-6781 ❑ Lodi -3621 Applicant - Return all copies to:,Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box.2009, Stk., CA 95201 1 DK RECEIVED BY DATE PERMIT NO. FEE AMOUNT DUE AMOUNT REMITTED C p(f ) f INFO I �-so� �� l�� • + EH 13-24 tREV-t EH 14-26 .. .. ..