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_ APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA - a Telephone (209) 466-6781 ,.- PERMIT EXPIRES 1 YEAR FROM DATE ISSUED T � (Complete in Triplicate) l�r install the work This cation is Application is heieby moi to the aJou Qui Local nee No.ealth District for sewage or mit No�1862 far construct eii/pump and the R l s and herein Regulations of the San r Joaquin made in compliance with San JoaquinCounty Local Health District, City Lot Size PM Job Address a Phone Address Owner's Name !� p`Address Address License Noat? Phone 3 Contractor DESTRUCTION ❑ WELLIP..UMP: N.W WELL�0L.� '�; WELL REPLACEMENT�I]� TYPE.OF -�-�------_ -- - - OTHER ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ - } DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES _��- DISPOSAL FILO.— SEWER LINE FOUNDATION - AGRICULTURE WELL "OTHER WELL PITS/SUMPS 1a E INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing i ❑,Industrial >(Open Bottom ❑ Manteca Dia. of Well Excavation --.:. pecifi k ❑ cations ` Domestic)Private ❑ Gravel PacTracy '' Type of Casing R v t-1 Other Cl Delta Depth of Grout Seal Type of rout >Crk F.1 Public al�J r/N I Irrigation �_�.Approx*Depth I I Eastern Surface Seal Installed by -- H P State Work Done _ k Repair Work Done r❑_ Type of Pump — Sealing Material (top 50'1 m r "WeII Diameter Well Destruction ❑,.' Depth -Filler_Material113elow 60'1 . '� _, T YP.E_OF..SEPTlC WORK: .NLW 11+STALLA TIO AJ REPAIR].ADDITION,I_I_DESTRUCTION 1 1.aNailabptic sYbtt:l wthin 200 feet11 itled if public sewer is i Installation will serve: Residence-�} Commercial— Other Number of living units: 'f! -Number of bedrooms _ r Water table depth - r , _Ch"racterrof soil to_a-depth of:3,feet: - No. Compartments NK ❑ Type/Mfg SEPTIC TACapacity I + 1 '� Method of Disposal PKG. TREATMENT PLT. L1 T- k � Distance to nearest; Well Foundation Property Line Total length/size F r. LEACHING LINE ❑ No. & Length,ol tines I Property Line 1' FILTER BED ❑ Distance to nearest: Well Foundation A Number ` t SEEPAGE PITS I 1 Depth Size " SUMPS �l Distance to nearest: ; Weil Foundation Property Line iDISPOSAL PONDS ❑ ""'" F 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 C rules and regulations of the San Joaquin Local Health District. + t Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, 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-contracting signature r certifies the following: "I certify that in the performance of the wofk for which this permit is issued, I shall employ persons subject to workman's compensa I tion laws of California." The applicant mu t.call for-alt.requir, inspectit9ns.Complete drawing-on -side. r Title: Date: Signed FOR DEPARTMENT USE ONLY d Date �.r :ffArea f Application Accepted by Final Inspection by Date Pit or Grout Inspection by Date �� ✓ Additional Comments: ❑ Stk 466-6781 C] LodiP.O.Lodi 369-3621I 69-3621 ❑ Manteca 823 7104 ❑ Tracy 835-6386 Ave.,., P. r Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton AvBox 2009, 5tkv, CA 95201 i _ 4 K RECEIVED BY DATE PERMIT NO. EEE AMOUNT DUE AMOUNT REMITTED CCASH INFO + EH 1324(REV.1/A 5) EH 14-26