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APPLICATION FOR PERMIT !I SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 9 YEAR FROM DATE ISSUED " (Complete in Triplicate) :This licatiori is i Application is hereby made to the San Joaquin Local d ordiHealth District for a nance No.549 for sewage or permit No 1862 forcwellspump atnd the Ruall the les and Regulationrk herein s of the San Joaquin P made in compliance with San Joaquin County ` Local Health District. PM " U r I Cit y_ ='=� Lot Size r Job Address � I � f �r Phone V Address _ , Owner's Name. 5bC- License No. '-i phone_ Contractost A rj nit TKI� f ��NS(Address pESTAUCTION ❑ NEW WELL ❑ WELL REPLACEMENT ❑ OTHER L1TYPE OF WELL/PUMP: i SYSTEM REPAIR ❑ PUMP INSTALLATION ❑ DISPOSAL FLD. PROP. LINE —��— DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PITSISUMPSAGRICULTURE WELL OTHER WELL FOUNDATION INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS pia. of Well Casing Dia. of Well Excavation E3 Industrial ❑ Open Bottom ❑ Manteca Specifications i ❑ Tracy Type of Casing -. LJ Domestic/Private ❑ Gravel Pack Type of Grout ' F1 .Other ❑ Delta Depth of Grout Seal U" t"1 Public' i,. Surface Seal Installed by ' 11 Irrigation --Approx. Depth I 1 Eastern State Work Done H.P. Ln Repair Work Done ❑ Type of Pump Sealing Material Rop 50'l Well Destruction 1-1W1. Diameter Filler Material IBeiow 501 - Depth STRUCTION 1-1 �INO'septic-system permitted if public sewer is TYPE OF SEPTIC WORK: NEW INSTALLATION i I REPAIR/AD DITION i available within 200 feet.) Other—__�-- installation will serve: - Residence Commercial_ f m r rr Number of bedrooms�— _ " - Number of living units: t. Water table depth -1 Character of soil to a depth'of,3 feet: Gapacity�� No. Compartments SEPTIC TANKV r ❑:i Type/Mfg Method of Disposal r' PKG. TREATMENT PLT. ❑1i Property Line Y; !i Distance to nearest: Well� Foundation Total length/size LEACHING LINE r & Length of lines s Property Line FILTER BED _� — ❑ Distance to nearest: . Well Foundation —� y r - -0 "l Number SEEPAGE PITS" I i' Depth Size -� SUMPS L1 Distance to nearest: Well "Fo dation Property Line DISPOSAL PONDS 0_ 1 hereby certify that I have'J epared this application and that the.work wiill be done in accordance with San Joaquin county;rirdinances, state laws, and rules and regulations of the San Jsignature aquin Local Health!District. g work for Home owner or licensed agent's anner nlowl torbecome subject the.flto workman's compensation lthat in the awsOfperformanceofifY Contractor's srhiringr op sub contract ng signermit is issued, I lature employ any person in sucpersons subject to workman's compensa- c Ties the following: "I certify that in the performance of the work for which this permit is issued, I shall employ tion of California." — he applic ust call f "all re fired i pectio m to drawing on reverse side. Date: Title: Signe FOR DEPARTMENT USE ONLY r !� _ .Date U�}' Area U Application Accepted by., � Final inspection by Data Pit or Grout Inspection by Date_� E Additional Comments: Cl Stk 466-6781 O Lodi 369-3621 El Manteca 823-7104 ❑ Tracy 835-6385 pies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 Applicant Return all co CK RECEIVED 9Y DATE PERMIT NO. FEE AMOUNT DUE AMOUNT REMITTED H INFO �!! -7-ja rEH1324tREV.t/k51 04� EH 14.26 - _.