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l� 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 (Complete in Triplicate) t and/or ll the work 'I wdon is Application is hereby thade to the I San Joaquan County Ordinance No.Districtalth 549 for sewage or permit to 1862 forcwell/pump and he Rules and herein ati�of he Sans Joaqu n made in compliance with r Local Health District. fig. F r r '7 i.; 1�f Lot Size X IL PM P /�' City 4 Job Address E �.e�� Phone Owner's Name Address License No. Contractor �' Address NEW WELL LJ WELL REPLACEMENT E3 DESTRUCTION C1YPEL TE OF WL/PUMP: SYSTEM REPAIR 11OTHER ❑ PUMP INSTALLATION El t: DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE i FOUNDATION AGRICULTURE WELL � OTHER WELL— IN-TENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing 1 r 1 ❑ Open Bottom ❑ Manteca Dia. of Well Excavation ❑ Industrial �' Specifications Type of Casing- ❑ Domestic/Private ED Gravel Pack ❑ Tracy .� De6th of Grout Seal Type of Grout- 0 Public rout❑ Public ❑ Other C3Delta V- p __ u _ .: : �Appr ❑ Irrigation ! ox. Depth ❑ Eastern } Surface Seel Installed by , H P State Work Done Repair Work Ddne ❑ Type of Pump Sealing Material (top 501 L Well Destruction e#Well Diameter t ' is Depth i Filler Material (Belo ',50'► Mo sept TYPE OF SEPTIC WORK: NEW INSTALLATION ❑� REPAIR/ADDITION l DESTRUCTION ❑ availabllelwthine200 feet.)permitif public sewer is Installation will serve: Residence �-Commercial Other {-' 1tjL i Number of living units: Number of bedrooms y Water table depth Character of soil to a depth of 3 feet: ' " " • -Capacity No. Compartments ❑ Type/Mfg SEPTIC TANK Lam. , Method of Disposal PKG. TREATMENT PLT. ❑ i r Property Line - Distance to nearest:r Well '' Foundation----i° -- # A., - +Total length/size LEACHING LINE ❑ No..& Length of lines . Property Line FILTER BED ❑ Distance to nearest: Well �-�^ Foundation' I r� i N SEEPAGE PITS (`Depth �+ Size Ij� QI umber Line Foundation� d� Property SUMPS - . Distance to nearest: I Well �`— i 1 _ 9 DISPOSAL PONDS ❑ I cation and that the work will be done in accordance with San Joaquin county ordinances, state laws, and hereby certify that I have prepared this appli rules and regulations of the San Joaquin Local Health District. l. 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 not employ any person in such manner as to become subject to workman's compensation laws of California:" ploy ceo�nshiring subj subject to workmanlsgcompensa- certifies the following:"I certify that in the performance of the work for which this permit is issued,l shall employ p tion laws of California." I ' t The app��irecl inspections. Complete drawing on reverse side. a '_' L.. Date: a Title: Signed i t x ( FOR DEPARTMENT USE ONLY Area J Date Q' F�}fir s Application Accepted by y 4� -79 Date Final Inspection by Date Pit or Grout Inspection by r 1 U , Additional Comments: a�" ❑ Stk 466-6781 ❑ Lodi 369 3621. • Manteca 823-7104 - ❑ racy Applicant- Return all copies to: Environmental Health Permit/Services 1601,E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 CK RECEIVED BY DATE PERMIT NO. FEEEAMOUNT DUE AMOUNT REMITTED CASH INFO �� - 157 + EH 1324{REV.5/e s] � EH 14-28