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APPLICATION EOR PERMIT AN JOAQUIN LOCAL.HEALTH DISTRICT �. TOCKTON, CA r 1601 e. I-IAZELTON AVE„ 5 ' hone (209) 466-6781 Telep IDATE ISSUED x PERMIT EXPIRES 1 YEAR FROM (Complete in Triplicate) application is u tions of tht San Joaquin or No. con for Fell/pump and the Rules and Rep ` , e to the San Joaquin Local Health District fora permit to construct and/or install the work hereis��described. This Application is hereby madsewage041 QSD made in compliance with San Joaquin County Ordinance No.549 for Local Health District. / 1 PM ��l Lot Size I Job Address 215- ai9T® I_ Q. 2 ( � JYTp /Sy�Z Phone f Address (-70 IJ Owner's Name C(t�s�, Contractor h AddressT&5X a foVtS S7L License No. �/ 07� Phone TYPE OF WELL/PUMP: NEW WELL C3 WELL REPLACEMENT L1 ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER �,AryONiT�IZtN� l —DISTANCE-TO NEAREST:.,SEPTIC TANK-Azli --— SEWER.LINES .1�_. DISPOSAL FLD.1PROP. LINE FOUNDATION Z.S AGRICULTURE WELL THER WELL P1TS15UMPS zO INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS El industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing �.._ {� Domestic/Private Gravel Pack ❑ Tracy Type of Casing ' Specifications Salt 40 f"1 Public Cn Other n Delta Depth of Grout Seal C'rf RrAC,9f •Type of Grout CPn�ru _ I I Irrigation '..Approx. Depth I 1 Eastern Surface Seal installed by CSO rTCeC�t� Repair Work Done ❑ Type of Pump H.P.. ~ ; State Work Done _ Well Destruction ❑ Well Diameter Seating Material (top 50') _PAol?it Depth Filler Material (Below 501 bpWeOff e/ —_ TYPE OF SEPTIC WORK: NEW INSTALLATION [] REPAIR/ADDITION 1 I: DESTRUCTION I I INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence— Commercial -- .Other Number of living units: —_ Number of bedrooms Character of soil to a depth of 3 feet: + ! Water table depth _ - SEPTIC TANK ❑ Type/Mfg Capacity_ No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property.Line I 4e t LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED C] Distance to nearest: Well Foundation Property Line j SEEPAGE PITS I $ Depth Size Number SUMPS - Lv� `WeN' Foundatsbn" 'T""`' rProperty Line'' --- -` DISPOSAL PONDS Q 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 DiMrict. 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 shall not employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." i The applicant m st c or all re ired inspections. Complete drawing on reverse side. Signed X Title: Date: # FOR DEPARTMENT USE ONLY Application Accepted by _ Date ti w Area �yt ' Pit or Grout Inspection by Date Final Inspection by Date t -• Additional Comments: _ Cl Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 nn Applicant - Return all copies to! Environmental Health Permit/Services 1601 E. Hazetton Ave., P.O. Box 2009, Stk.; CA 95201 FEEAMOUNT DUE AMOUNT REMITTEO CK INFO CASH RECEIVED BY DATE PERMIT NO. .`EH13-24 iREv.r i w 5) EH tI-I9 f