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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT k 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) t to construct f install the work herein ribe ,This cation is made�nl compliance vv hdSanoJoaqu nthe SanCoungty O diJoauin nalnce No.549 for sewage orHealth District for a 'No. 1862 for well/Puomp and the Runes and Regulations of the San r Joaquin Local Health District. 004"` City Lot Size — PM Job Address Address - Phone. Owner's Name 1 • /! (% Contractor dress License No.l�_Phone TYPE OF WELD PUM NEW WELL ❑ WELL REPLACEME ❑ DESTRUCTION ❑ PUMP INSTALLATION El SYSTEM REPAIR ❑ OTHER 171 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL— INTENDED INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Ll Industrial LJ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Type of Casing_ Specifications ❑ Domestic/Private El Gravel Pack ❑Tracy ypT of Grout - [-I Public ❑ Other 1_1 Delta Depth of Grout Seal __ Type I Irrigation —.Approx. Depth I I Eastern Surface Seal Installed by -- f Repair Work Done L1 Type of Pump _ H.P. _ State Work Done_ Well Destruction U Well Diameter Sealing Material Stop 50"I ?/ Depth Filler Material (Belo ) spQ j TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I -DESTRUCTION f I (No septic system permitted if public sewer s I I available,within 200 feet.) r Installation will serve: Residence_ Commercial -_ Other ` Number of living units: -,V- Number of bedrooms r. Il Character of soil to a depth of 3 feet: Water table depth_- SEPTIC TANK ❑ Type/Mfg Capacity I No. Compartments t PKG. TREATMENT PLT. ❑ ) F — Method o1 DisLJ rA ;� Distance to nearest: Well- -Foundation Property line EACHING L1NE ❑ No. & Lengthof lines nTotal length/size F BED ❑ Distance to nearest: WellFoundation _V Property tine AGE 41,) Depth Size Number T 1_D SUMPS �� Distance to nearest: Well��" Foundation Q0` _ Property Line DISPOSAL PONDS ❑ I 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 liconsed 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." The applicant t c r req nspactions. Co etc drawing on re !Fs side. ` Signed X Title: Date: F DEPARTMENT USE ONLY Date `2 Area Application Accepted by !` - _ Iit _ Date I Final Inspection by — Date � Pit or Grout Inspection by i i 1. 61 Additional Comments:• ❑ Stk 466-6781 G Lodi 369-3621 C3 Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk-, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE q(� PERMIT NO. N s, 11,7 EH13- (REV.iies) � ..J �/�� O 1 EH 11426 � \