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APPLICATION.FOR PERMIT . J SAN JOAO.UIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE.,..STOCKTON, CA Telephone 1209? 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED..;; (Complete in Triplicate),: li application is construct and/or all the work Application is heieeyNmh San the Joaquin nJoaquin Local Health County Ordnance No.549-f or sewage or istrict for a permit to desc 1862 for weil/pump and the Rules and hereinR Regulations of he San Joaquin made in compliantr - a nt-.,.,,,, ` Local Health District. City 707 if 10111111,11 <' Job Address w _ � f Phone iQ k' ddress Owner's Name e Phone_ Address License No. Contractor a DST ION r WELL REPLAGEMENT. ❑ � TYPE OF WELL/ ,. �.- --NEW WELL ❑ OTHER ❑ PUMP INSTALLATION ❑ ( SYSTEM REPAIR El SEWER LINES_, '�" IDISPDSAL FLD. t PROP. LINE �/ DISTANCE TO NEAREST: SEPTIC TANK OTHER WELL PITSlSUMPS FOUNDATION — AGRICULTURE WELT I INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPEC ,CATIONS Dia. of Well Casing ❑ Open Bottom 0 Manteca Dia.'of"Well Excavation El Industrial t T e of Casing Specifications El Domestic/Private E3 Gravel Pack Ll Tracy yp 1Type of Grout ! ❑ Other El Delta Depth of Grout Seal ❑ Public Surface Seal Installed by LL`"=�4pprox. Depth ❑ Eastern ❑ irrigation State Work Do e— e of Pum H.P. Re air Work Done ❑ TYP p !t Sealing Material (top 50'i t Well Destruction X Well Diameter A� Depth Filler Material iBelow'501 TYPE OF SEPTIC WORK: NEW I S ALLATION C1REPAIR/ADDITION ❑,,,,.DESTRUCTION ❑ alvailabperwithsn 200 fetem et.) if public sewer is Installation will serve: Residence Commercial Other Number of living units: Number of bedrooms s�. T �.. Water table depth k Character of soil to a depth of 3 feet: Capacity No. Compartments SEPTIC TANK ❑ TypelMfg Method of Disposal PKG. TREATMENT PLT. ❑ Property Line Distance to nearest: Well Foundation p rhr Y M, Total length/size LEACHING LINE ❑ No. & Length of lines Foundation Property-Pro a Line FILTER BED ❑ Distance to nearest: Well � Size Number SEEPAGE PITS ❑ Depth rFoundation Property Line SUMPS 0 Distance to nearest: Weil I 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: "I certify that in the performance of the work for which this permit is issued, i signature shatl not s of employ any following:"I certify ertify that ino become theperformance of toworkman's wok forswhich this tpenpaws issued, Ihall employ personshiring subject to workman's -contracting certifies the fo g tion laws of California.".. e The applicant must call r all required inspections. Complete drawing Title: Date: �f on reverse side. f r s'4'� . - I Signed X r FOR DEPARTMENT USE ONLY Date �� Area �. Application Accepted by ✓� Pit or Grout Inspection {t4h pate Final Inspection by`" Date Additional Comments: ❑ Stk 466-6781 F.Lodi 369 3621 ❑ Manteca 823-7104 i EJ Tracy 835-6385., P.O. Box 2009, Stk., CA 95201 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P. D RECEIVED BY ' DATE PERMIT N0. FEE AMOUNT DUE a AMOUNT REMITTED C SH 1 INFO / + EN 13-241REV.t ,� EH 44-26