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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED (Complete in Triplicate) ork cation is Application is hereby madeSanothe Joa Joaquin County OLocal nHealth fe a1 o.549 for sewage or permit No. 1862 for well//pump and the Rules s and herein Regulations of tlhe Sanis r Joaquin made in compliance with q ,- t `9�cuL+� Local Health District. :1 1� W 4 ti / � City %6G ti Lot Size �- PM Job Address t f t dOw �; t r�dt�� tf�7�O�/tJ!/{ Address Phone Owner's Name ,7 - y Contractor f—�iGG �� ,., Phone Address License No. WELL REPLACEMENT C3DESTRUCTION"❑ TYPE OF WELL/PUMP: NEW WELL ❑ ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER � } SEWER LINES DISPOSAL FLD. 1� PROP,kLIN E Q DISTANCE TO NEAREST: SEPTIC TANK �` plT51SUM'PS FOUNDATIOI F`- _ - .- -_ AGRIGULTAE-WELL OTHER WELL s' * - i INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFIGATION5 Dia of VVell Casing ❑ Industrial ❑ Open;Biittorn ❑ Manteca Dia. of Well Excavation t Type of Casing Specifications ❑ Domestic/Private ❑'Grav'el Pack ❑ Tracy Type of Grout I-]i Public El Other r Delta Depth of Grout Seal e s� _Apprasc. Depth t I Eastern Surface Seal Installed by t i I I Irrigation S 1 H.P. State Work Done _ `.;'., i Repair Work Gone ❑ -Type of Pump s ii Well Destruction ❑ Well Diameter Sealing Material atop 50'l Depth t Filler Material (Below 50'I TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIRIAODITION I I DESTRUCTION I'I (No seailabpeswthisystem per fee r1)tdd'�frpubli sewer is II41 Commercial Other installation will serve: Residence' i Number of bedrooms._ ' R Number of living units: l � Water table,depth , Character of soil to a depth of 3 feet: r. ' Capacityl_[ts-_ No. Compartments ! ' SEPTIC TANK ElType/Mfg Method of Disposal ' f PKG. TREATMENT PLT. ❑ -, s Ct10' Tbu' dation Property Line �7 Distance to nearest: Well, � �•tip. '` . l.s i t: Total length/size LEACHING LINE � ❑ No. & Length of lines _ / Foundation 1 Property Line— -- FILTER SED ❑ Distance to nearest: Well — I Number 4 SEEPAGE PITS I 1 Depth I Size Property Line } k SUMPS L1 Distance to nearest: Well Foundation i DISPOSAL PONDS ' will la�,done in accordance with San Joaquin county ordinances, state.Vows, and I herehy certify that I have prepared this application and Ahat-the work rules and regulations of the San Joaquin LocaIJHealth District.'g 1 =' Home owner or licensed agent's signature certifies the faliawing: "I certify-fhat iriithe performance of the work for wh ich this permit is issued,!l shall not employ any person in such manner as io become subject to workman's compensation laws of California." Contractor's orto -contracting certifies the following: "i certify that iri the pensa- perfoFinance of•the work for which this permit is issued,1 shall employ psubject tion laws of California." ; The applicant must call for al eqi fired inspecti s. Complete drawing on reverse side: Title: 1 Ay+ � _ Date: Signed X r �' FOR DEPARTMENT SE ONLY 1 ..,- P Area Date Application Accept! by Date Pit or Grout Inspection by Date Final Inspection by f Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy Stk., CA 95201 Applicant Return all copies to: Environmental Health Permit/services 1601_E:-Hazelton,Ay$.. P•d•.Bbx_2QD9, "'-' -K RECEIVED 8Y' K. DATE PERMIT-NO. FEE -.AMOUNT DUE"--" -"AMOCJNT-REMITrED � CASH' ,F yINFO r PH 13-241REV.1/95f ✓�/ � �� EH 14-26 ,