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VV0 S 6,q,6 i APPLICATION FOR PERMIT ` SAN JOAQUIN LOCAL HEALTH DISTRICT AVE., STOCKTON, CA 1601 E. HAZEL T,�N.r } Vephon'(2091.466-6781 PERMIT EXPIRES 1 YEAR'FROM DATE 'ISSUED lC6mplete�in�Triplicatel: ` 1#3..: ....�„ r.�`iutcf r. ' `'rt^;r! .This Iication is I Application is hereby made to th6 Joaquin County Ordinalnce No.DistrictH"ith 549 for sewage permit No._1862.f or weA/dpump and the Roles and ll the work herein Regulations sof the San Joaquin r l made in compliance with San Joaquin. 17 _ Local Health Distrix s..�.� .1 1 t, r i Job Address ;y It ,..'F Phone Owner's Name l d 6 �r• one ,:License No. Contractor VI/ELt RSP a'EMENT ❑ DESTRUCTION 12TYPE OF WELLIPUMP: NEW WELL ❑ / 1 OTHER ❑ PUMP INSTALLATION [E� SYSTEM REPAIR ❑ lPROP-.LINE DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL-'jp1 i —�—.�..^-..�----• i �— PITS/SUMPS OTHER WELL FOUNDATION � r AGRICULTURE WELL INTENDED USE TYPE OF WELL PROBLEM•AREA`" CON�TRUCT101V'SPECIFICATIONS Dia of Well Casing Dia. of Well Excavation # ❑ Industrial ❑ Open Bottom El Manteca Specifications ❑ []Tracy Type of Casing Type of Grout ❑ Domestic/Private Gravel Pack �� Delta Depth of Grout Seal • Public C1 Other ---Approx. D pth i❑ Eastern Surface Seal Installed by11 1110�10 11111 . I ❑ Irrigation -/ H P State Work Done Repair Work Done lied' Type of Pump �1yy��= in Well Destruction Eli Sealing Material (top 50') Well Diameter �T— -i l Depth I Filler Material (Below 50') available within 200 feet.) [: TYPE OF SEPTIC WORK: NEW INSTALLATION) ❑ REPAIRIADDITION ❑ DESTRUCTION 13 (No septic system permitted if public sewer is 4 1: Installation will serve: Residence� Commercial— Other Number of living units: Number of bedroomsWates table depth Character of soil to a depth of 3 feet: . Capacity— No. ('compartments SEPTIC TANK ❑ Type/Mfg Method of Disposal PKG. TREATMENT PLT. ❑ L Foundation��— Property Line Distance to nearest: Well �o rr Total length/size t, LEACHING-LINE `m No. & Length of lines property Line l FILTER BED ❑',Distance to nearest: , Well Foundation �t `1�.j `Size Number SEEPAGE"P1TS ' 1'�!-Depth Foundation Property Line SUMPS aJ DistanIlNlell ce to nearest: w DISPOSAL ❑ - I hereby certify that �epated-this application ani)that the work will be done in accordance with San Joaq uiri county ordi pces,`stat Iawf^,; and rules and regul ns of the n Joaquin Local Health District. -" "I certify that in the performance of-the work for,+�;�,;4 r ti+1if is issued sill not I ature Home net r licensed agent signature certifies the following: employ an person irr such ma net as ta`become su ect tow m n's compe tion laws of California." Contractors hirirt °asub contracti certifies a following`."1 ceri I at in the perform f t wo for whic is per is issued,I shalliYlploy persons suo waFnan's ansa tion la of Calif rnia." e draw r' .r The a plicant al or, requirj inspe~ ing n-rev rde. 3 1 Signe A CX)� ' r - F DEPARTMENT USE ONLY _ cm � C+3 1 Date _. . —, Application Accepted by a k ate r Da 4 Final Inspection by Pit or Grout Inspection by Additional Comments: ❑5tk 466 5781 ❑ Lodi"�369-3621 C3 Manteca 823-7104 ❑ Tracy 835-6385 nvironmental Health Permit/Sgrvices 1601 E. Hazelton Ave., P.O-Box 2009, Stk., CA 45201 Applicant- Return all copies to: E PERMIT1NO. AMOUNT REIIALTTE6 � RECEIVED By.,,. . DATE FEE AMOUNT.DUE GASH �w k,. - gb ~Sq INFO. + EH 13-24{REV.1 a 6) EH 14-26