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APP.rI 'CA TION FOR PERMIT SAT! JOAQUIN LOCAL HEALTH DISTPICT � 1601 E, HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) t andY or install the work cation is rApplication is ado in compliance vith San Joaquin County ordinance ade to thp San Joequin lHealth Distric No.549 for sewage or permit 1862 fnrcwell pump and the Rules and tRegulatio Regulations of the Sent Joaquin Local Health District. r 4 G ! � e - J City jNy_ Lot Size PM ob A J cJ [i� Address —_+ �7_(J+� Phone I } Owner's�:ame�L:--/�/�- � ws e A .y 1yF,/ Address_ s � `-2T --License NorSr �— Phone S _ Contractor —(1[�L�� - TYPE OF WELL/PUMP: NEW WEI-L rti] WELL REPLACEMENT L7 DESTt UCTION ❑ PUMP INSTALLATION 11 SYSTEM REPAIR C]' OTHER ❑ DISPOSAt FLD. PROP.LINE I DISTANCE TO NEAREST: SEPTIC TANK —_. SEWER LINES OTHER WELL P1T5/SUMPS _ !' _FOUNDATION _ AGRICULTURE WELL + INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia of yal:Cd:etl t ❑ Industrial ❑ Open Bottom C] Manteca ilia, of Well Excavation , Trac Type of Casing Specificatlons ❑Doraestic;Private 11 Gravel Pack ❑, Y 7 of Grout. — ❑ Public ❑Othor ❑ Delta Depth of Grout Seal _ tips Q O Irrigation ---Approx. Depth C Eastern Surface Seal installed try lyV i H p State Work Done Repair Work Done C TYPO of Pump O� Sealing Material Itop 50'1 Well Destruction C3 Well Diameter ! Depth Filler Motorial(Below 50') -- tINo . I TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIAlADDITION�t DESTRUCTION❑ availablerwithina20feet.) ed if public sewer is I]WillInstallation will serve: Residence Commercial Other Number of living units: Number of bedrOOMS N .� A-#A1 4 — Watet table depth Character of soil to a depth of 3 feet:— — — No. Compartments C TANK ❑ Type/Mfg SEPTI Capacity__ 1.1 I Method of Disposal PKG.TREATMENT PLT.❑ PropertyLine - i Distance to nearest: Well Foundation i LEACHING LINE No.ti,'kength of lines _ Total lengthisize ;j Distance to nearest:: Well ��Foundation 1Q_f Property Line + �� f FILTER BED Dumber s I. SEEPAGE PITS ❑ Depth — Site - SUMPS Q Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ ! I hereby certify that I have prepared this applicatio,..rid that the work will be done in accordance with San'Joaquin county,ordinances,state,ewe,and rules and regulations of the San Joaquin Local Health District. Home owner or licensed agents signature certifies the following:"I certity that in the performance od the work for which this permit Is-contracting i shell not employ any person in such manner as to become subject ro workman's compensation laws of California."Contractor's hiring or su�contraoting signature ? certifies the following:"t certify that in the performance of the work for which this permit is issued,t shall employ persons subject to workmen's oompensa• tion laws ct California." The applicant must call r all A;d. flails. CompEeta drawing on reverse side. i� Title: Date: Signed X. -A ; FOR LEPARTMENT USE ONLY r # ! ` 1`1 Data Applicetion Accepted by att -- r } s i • -�9 ,� f Data Final Inspection by Date's .,� • Pit or Grout inspection by Additional Comments: 71W L7 Trtrcy g��5 I7 Sok 466-6781 ❑ Lodi 369-3621 enface 823•. { urant-Return all copies to:.Environmental Haalt PsrmitIService3 1601 E. Hazelton Ave., P. Appi`• O.Box 2009. Stk.,CA 95201 x F K A RECEIVED SY DATE PERMIT NO. i. FEE AMOUNTDUE AMOUNT gEMITTEO GASH INFO !• •EH 13 (REV,1�l51 s` ter 14'1$ ^/-T-_ 4'f k Z I SEWER