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APPLICATION FOR PERMIT , SAN JOAQUIN .LOCAL HEALTH DISTRICT 1601 E. HAZEL—I ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED r� ,(Complete in,Triplicate) r1 'O . application s oun Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Application s hereby made toile San Joaquin Local Health District for a permit to construct and/or install the wok herein described. s apP made in compliance with San Joaquin C tl+ _ Pl' y `d kc�Pl�l Local Health District.' ..; �' r City '^ Lot Size / Job Address S , Phone 1e T 79 Address # _ :- Owner's Name s J. License No. Phone' Address Contractor WELL REPLACEMENT ❑ DESTRUCTION i> 1 NEW WELL ❑ ; { TYPE OF WELL/PUMP SYSTEM REPAIR ❑ a OTHER ❑ PUMP INSTALLATION ❑ p15POSAL FLD. PROP. LINE, SEWER LINES �= : PITSISUMPS ` DISTANCE TO NEAREST: SEPTIC TANK —� AGRICULTURE WELL OTHER WELL FOUNDATION 1 y L + 1 f INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION Well x SPECIFICATIONSpia. of Well Casing s ❑ Open Bottom ❑ Manteca Dia. of Well Excavation ❑ industrial Specifications 4 ❑ Tracy ,Type of Casing Type of Grout p Domestic/Private [_3 Gravel Pack ❑ Delta Depth of Grout Seal j 1 ❑ Public ❑ Other j --Approx. Depth El Surface Seat installed by (D ; � —.-• `- S Irrigation " State Work Done— y Repair Work Done ❑• Type-Of Pump L Well Diameter Sealing Material (top 50') Well Destruction ❑ Depth Filler Material (Below 50') available within 200 feet.) l i .. TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIflIADD1TiON ❑ DESTRUCTION ❑ (No septic system permitted if publicsewer�s r r Installation will serve: Residence Commercial f Other_w�--- t Number of bedrooms ' N,� l Number of living units: y (Nater table depth ' Character of soil to a depth of 3 feet:IMfCapacity No. Compartments '❑ Typeg ' SEPTIC TANK Method Disposal PKG.'TREATMENr PLT. ❑ Pro a Line Distance to nearest: Well Foundation P '�' LEACHING LINE ❑ No. & Length'af_lines Total length/size ! k° Foundation Property Line; FILTER BED ❑ Distance to nearest:,`• Well' Size Number—' SEEPAGE PITS El Depth Foundation Property Line i SUMPS ❑ Distance to nearest: Well 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, and rules and regulations of the San Joaquin Local Health District. Home owner"or licensed agent's signature certifies the following: �L.cert9fy that in the performance of the work for which this permit.i§•issued, l signature spa not tion of California." employ any person in such manthat n the peome rformance of the wok for which t to workman's ch this permit issued, I shall employ personslsubjecring rt to orkmanEsgcompeilsa cert-rfies the following: '9 certify �' ; y tion laws of California." f 3, s The applicant must call for all required ins t' ns Complete drawing on reverse side. - Date: i i Signed X Title: FOR DEPARTMENT USE ONLY t I Date Area —l � ` �..: I a Application Accepted by I 17ate r zDate Final Inspection by Pit or Grout Inspection by Al Additional Comments: .N: 5tk 466 6781 ❑ Lodi 369 t Manteca 823-7104 ❑ Tracy 835 6385 t;=" all COOes to: Environmental Health Permit/,Services 1601 E. Hazelton Ave., P.O. Boz 2009, Stk., CA 95201 Applicant-,Return RECEIVER BY DATE PERMIT NO. FEE AMOUNT DUE AMOUNT REMITTED A '." INFO + EH 13-24(REV. EH 14-28