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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1'YEAR FROM DATE ISSUED I (Complete in Triplicate) /or install the work . This Application is lance made n the Joaquin county ordinance ltNo.549 for sewage or ealth District for a permit Nv 1862 for well/pump and the Rules and herein R Regulations of he Santcation is Joaquin made in compliance with San Joaquin Local Health District. 9City Lot Size PM Job Address jqwq9 f-•`:� � I1, qi Q \ dress ry (",�" �' Phone Owner'§ Name �, .�✓ b� ��r -7 Contract Address �0.: 1w 1 License Nola z _Phone_ TYPE OF WELL/PUMP: NEW WELL [3// WELL REPLACEMENT ❑ DESTRUCTION ❑ Irl'. SYSTEM-REPAIR Ll OTHER 11A ' (SUMP INSTALLATION,.❑ X DISPOSAL FLD. PROP. LINE t ,C _�. DISTANCE TO NEAREST: SEPTIC TANK SEW' i Efl LINES f FOUNDATION- Z . `AGRICULTURE WELL OTHER,WELL ' ,P.ITSISUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS j Dia. of Well Casing ❑ Industrial ❑ Open Bottom j❑ Manteca ' Dia. of Well Excavation 11 Type of1Casi`g 1-N Specifications ❑ Domestic/Private ❑ Gravel Pack / EJ Tracy r 1 YP Type of Grout-- J rout k 4r Cl Other I ❑ Delta ,` Depth of Grout Seal I - s i lz Cl Public ' '"� 1 - Approx. Depth i I Eastern Surface Seal Installed by #' %— I Irrigation State Work Done — �u p Repair Work Done 0 Type of Pumper H,P. Well Destruction ❑ Well piameterr + �- Sealing Material Itop 50'1 Depth � ler Material [Below 50'1 r TYPE OF SEPTIC WORK: NEW-lNSTALLATIrON-I=1 EPAIR ADDITION DESTRrUCTION I.I (No septic system_permitted,if-,)ublic sewer is 10_ �; �.� _ '.availablewithin200;feet.i :Installation Will'serves= Residence— Comm / ether I r 5 Number of living units: YNumber-o, a room , , ^� Y Water table depth L� Character of soil to a depth of 3 feet: No. Compartments SEPTIC TANK ❑ Type/Mfg -,Capacity ( Method of Disposal PKG. TREATMENT PLT. L3I } r Distance to nearest: Well Foundation �' Property Line ( c I Totallengthlsize rv, ' LEACHING LINE '❑ANO. & Len gth of lines property Line FILTER BED i ©�' Distance to nearest: Well Foundation l It I k SEEPAGE PITS Depth Size Nrmber 1 — 1' kFoundation''43 { i PeftY,Line a- SUMPS LI Distance to nearest: Well _ + DISPOSAL PONDS I :p f I hereby certify that 1'h'ave prepared this application and that the work`Vv b one 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: "I certify that in.the performance of the work for which this permit o6te u tin I shall not employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-coritr'acting signature certifies the following: "I-certify,that in the performance of the work for which this permit is issued,-1 shall employ persons subject to workman's compensa- { tion laws of California." t k t The applicant call for a r ui d inspections. Complete drawing on reverse;ido./� n Date: Signed X Title: -FOR-DEPARTMENT-USE-ONLY'- ... {� 1 Date Area Application Accepted by -- �- / or Grout Inspection by -� at Final Inspection' by Date i � 7� _ Additional Comments_: 835-6385-- ❑ Stk 466-6781 ❑ Lodi 369-3621 C3 Manta 823 7104 ❑ Tracy' , -- Applicant - Return all..copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 k r�, CK RECEIVED BY DATE PERMIT-NO. ffFE MOUNT DUE AMOUNT REMITTED CASHEH 13-24(REV.t - - 4 EH 14-2e N r