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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601E HAZE�TON AVE., STOCKTON, CA Telephone (209) 466-6781 ISSUED ' PERMIT EXPIRES 1 YEAR FROM DATE I (Complete.in Triplicate) `. .. k 6 lication is or No 1862 for welllpump and.the Rt;Ies and Regulations of the San Joaquin San Joaquin Local Health District for permit to construct and/or install the work herein described. This ap Application is hereby made to the Sa Ordinance No.549 for sewagec ` made in compliance with San Joaquin t unty Y �p0 '` M� Local Health District. Loi Size J` Job Address `,. - �--Sv . � -✓7'ff/' - Phone i Address ' jj 1.f �� Owner's Name fl ` License Niiiii rhone Address ( - DESTRUCTION p^ Contracto NEW WELL A- WELt REPLACEMENT ❑ OOT��H,E�R,© ' TYPE OF WELLIPUMP: SYSTEM REPAIR pISPOSAL FLD•Q�C PROP' LINEA I 4 PUMP INSTALLATION ❑ , SEINER LINES PITS/SUMPS� L1 DISTANCE TO NEAREST: Q OTHER WE SEPTIC TANK AGRICULTURE WELL y" l� + FOUNDATION 1 TYPE OF WELL PROBLEM CONSTRUCTION SPECIFICA IONS Dia. of Well Casi�G I INTENDED USE ❑ Manteca Dia. of Well Excavation Specifications P, n Bottom Type of Casing Type of ro ❑ Industrial ❑ Tracy ❑ Domestic/Private ❑ Gravel Pack - Depth of Grout Seal ❑ Other Q Delta d ublic �5urface Seal Installed by ��gpprox. Depth ❑ Eastern ,,, State Work Done tgatton H.P. Repair Work Done ❑ Type ofrPump Sealing Material ("top 501 Well'Destruction ❑ Well Diameter Filler Material (Below 50') Depth tic system permitted if public sewer is {„ F available within 200 feet.l TYPE OF SEPTIC WORK: NEW INSTALLATION ❑. REPAIRIADDITION ❑ DESTRUCTION Q lNo septic i i Commercial Other � } Y Installation will serve: Residence Water table depth Number of living units: .. Number of bedrooms ` No. Compartments G Character of soil to a depth of 3 feet: Capacity Method of Disposal i SEPTIC TANK ❑ TyPelMfg ' t Property Line PKG. TREATMENT PLT. ❑ ! Well Foundation Distance to nearest:_ " r I Total lengthlsize LEACHING LINE D No. & Length of lines Property Line Foundation —.—� dation FILTER BED Q Distance to nearest: Well 1— i. Number ! Size r SEEPAGE PITS ❑ Depth Foundation_� Property Line r I SUMPS ❑ . t stance to nearest: Well r—_ ate laws, and DISPOSAL PONDS have prepare this application and that the work will be done in accordance with San Joaquin cou thiordinance re�t ssssued I shall not I hereby certify that I P rules and regulations of the San Joaquin Local Health following: performance of the work for whit P compensation laws of California."Contracoshiring subject t workman'scompensa Home owner or licensed agent's signature certifies the followin I certify that in the pe employ any person in such manner as to become subject to workman's comps certifies the following:"I certify that in the performance of the work for which this permit is issued,l shall employ person k tion laws of California." e The applicant I all�equired inspections. Compl a drawing on reverse side. Date: 4 I' Title: Signed r O E ARTM T E ONLY ��'� l - Date rea / Application Accepted by r Date Date 9 8 Final Inspection by Pit or Grout Inspection by - - "� r 1 Additional Comments: ❑ Tracy 835-6385 r. X466-6781 ❑ Lodi 3643621 ❑ Manteca 823 7104 ► Applicant- Return all copies to: Environmental Health Permitl5ervices 1601 E. Hazelton Ave., P.O. Box 2009. Stk., CA 95201 ❑ Stk .. Y DATE PERMi CK RECEIVED BT•NO. r AMOUNT REMITTED, H FEE AMOUNT DUE INFO _ ,,.. -.... 3w +:EH.1324(REV.t/85) EH 14-26 �3oa •. - - ...