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r .. APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT . a 1601 E- HAZE T ON AVE., STOCKTON, CA I Telephone (209) 466-6781 PERMIT EXPIRES 1-YEAR FROM DATE ISSUED (Complete in Triplicate). he work herein cation is t and/or install madeincois mpliance wieteby th San Joaqude to the in County Ordinance No.549 lar n Joaquin Local Health District for a etewa8 or permit o. 1562 for to cwon/pump and the Rules and Regulations of This „he Sant Joaquin Local Health District. �.�_ -� i l City Lot Size PM Job Address - .�i�rrs�nr. Address Phone 33- Owner's Name { }a,T-�----r--� � f� Phone- I Contractor ` Address License No. TYPE OF WELLIPUMP: ONEW WELL D WELL REPLACEMENTGC DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER.LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Weil Excavation Dia. f Well Casing a ❑ Domestic/Private ❑ Gravel Pack ❑Tracy Type of Casing Specifications - Other ❑Delta Depth of Grout Seal Type of Grout � 3 FI Public , Irrigation - ,—Approx,-Depth _1 ]-EasternSurface Seal.installed by - 'Repair Work Done L7 Type of Pump �t[raA/� H•P• _ — State Work Dona 'R f Well Destruction EI Well Diameter SQalinp Ua op.50') Depth Fillet erial I Balow 50't l TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION i I DESTRUCTION I i available with 200 feet.) if public sewer is Installation will serve. Residence, ,Commercial— Other Number of living units: •Number of bedrooms 4 t' Character of soil to a depth of 3 feet: Water table depth r 1 tt V SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments r!y PKG. TREATMENT PLT.❑ Method of Disposal lJ t Distance to nearest: Weil Foundation Property Line LEACHING LINE 0 No. & Length of linea Total length/size CR FILTER BED ❑ Distance to nearest- WeN Foundation Property Line SEEPAGE PITS IA Dopth Size Number r SUMPS 0 Distance to nearest: Well Foundation Property Lirre DISPOSAL PONDS 0 t I hereby certify that 1 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 Dilitrict.F -.. 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,AI shall employ persons subject to workman's compensa- i�^- - -tion•laws'of California." The applicant must call for all required inspections. Complete drawing on reverse side" f /y Signed x Title: ` � - Date: q DEPARTMENT USE ONLY Q Application Accepted by �_ Date -�� ^0 Area Pit or Grout Inspection by Date Final Inspection by rn Date Additional Comments: ©Stk 466-6781 . ❑ Lodi 369.3621 0 Manteca 823-7104 ❑ Trat:y 835-63.85 k Applicant- Return all copies to: Environmental Health PermitlServicea 1£01 E. Hazelton Ave., P.O. Box 2009, Stk., CA 952M1 t FEE AAOUNT DUE AMOUNT REMITTED CK 6 GASH RECEIVED BY DATE PERMiT N0. INFO _ EH 1429 L3 6- t 1 '• .