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rt APPLICATION FOR PERMIT SAN gP4-UUI.lN LOCAL HEALTH DISTRICT 1601 E. HAZEL I ON AVE., STOCKTON, CA Telephone (209) 466-6781 r PERMIT EXPIRES TYEAR FROM DATE ISSUED 'I (Complete in Triplicate) application is Application is hereby No.549 for sewage or No. 1B62 for well/pump and the Rules and Regulations of the San Joaquin App 11 made to the San Joaquin Local Health District for a permit to construct andlor install the work herein described.This app made in compliance with San Joaquin County Ordinance Local Health District. li PM�--- Q tqK-, City tot Size Job Address 9 Phone .# Address Owner's Name License No. ---Phone_ l -DESTRUCTION,❑ w ContractorAddress,��— WELL REPLACEMENT ❑ . _ TYPE OF WELL/PUMP: NEW WELL ❑ _ - - OTHER El REPAIR ❑ PROP. LINE PUMP INSTALLATION ❑ DISPOSAL FLO. SEWER LINES �— PITS/SUMPS DISTANCE TO NEAREST: SEPTIC TANK AGRICULTURE WELL OTHER WELL FOUNDATION ��— INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS pia. of Well Casing ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Specifications ❑ Industrial ❑ Tracy Type of Casing _ ❑ Domestic/Private ❑ Grave! Pack Type of Grout F1 Other f-1 Delta Depth of Grout Seal rl Public Surface Seal Installed by I } Irrigation H.P. �! .Approx. Depth f I Eastern State Work Done - Repair Work Done ❑ Type of Pump Sealing Material Itop 50 well Destruction ❑ Well Diameter —�— 1 Depth Filler Material (Below 501 TYPE OF I 1 REPAIRIADQITION i ! DESTRUCTION-1 1 (No septic system available within 200 feet.)permitted if public sewer IS SEPTIC WORK: NEW INSTALLATION ( Commercial Other f Installation will serve: Residence— Number of living units: Number,of bedrooms Water table depth k Character of soil to a depth of 3 feet: Capacity— No. Compartments SEPTIC TANK ❑ I Type/Mfg Method of Disposal of PKG. TREATMENT PLT. ❑it_ y. Foundation Property Line-- Distance'to nearest: Well r FTotal length/size f LEACHING LINE ❑; No. & Length of lines Foundation_—_� Property Line FILTER BED D: Distance to nearest: Well Number. ze Si . SEEPAGE PITS I I Depth ' Property Line SUMPS ❑a Distance to nearest: Well Foundation DISPOSAL PONDS ❑ ' I hereby certify that l have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state taws, and rules and regulations of the San Joaquin Local Health District. g work shall not Home owner or licensed agent's signature certifies become s the folio wing: 111 ertcoympensation lthat in the aw soof Californ aha Co tractor s+hir g1 op sub-contracting ermit is issued, lsignature employ any person in such mannerarsons subject to workman's Compensa certifies the following:"I certify that in the performance of the work for which this permit is issued, I shall employ p tion laws of California." The applicant must call for all required inspections. Complete drawing on reverse side. Date: Title: ' Signed X FOR DEPARTMENT USE ONLY IDate Area Application Accepted by Date Pit or Grout Inspection by Date Final inspection.by k Additional Comments: p Stk 466-6761 Q Lodi 369-3621 ❑ Manteca 823 7104 ❑ Tracy B35-6385P.O. Box 2009. Stk., CA 95201 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P. ` CK RECEIVED BY DATE PERMIT NO. FEE AMOUNT-DUE AMOUNT REMITTED CASH INFO + EH 13-24 REV. EH 14-26 cy �h