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^� APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRIT DEC' tu2J9 1601 E. HAZELTON AVE., STOCKTON, CAHEATH Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (vi1 11SCRViCcS (Complete in Triplicate) t to t and/or install the work n describe . This cation is madeinti nL1 ompliance with made SanoJoaqu n County Ordinathe San Joaquin Localnce No.549 for sewage orHealth District for a 'No. 1862 for cwe l//pump and the Rules and'Regulations of the Sant Joaquin Local Health District. 1 / g�� i s S/�Ct2f- CitLot Size PM Job Address -I O Ky/� y L /20. CA Phone Owner's Name ,p" ,a/� t,,t _ Address /�O•/�Oir `S�a� / License No.Cs-A'%S_S'9WPhone Contractor�/E�+ z�^ Address,� �`� TYPE OF WELL/PUMP: NEW WELL 04 WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR 11 OTHER ❑m�^+•�O1L•y� /vs7YC" 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 _ Excavation Dia. of Well Casing y ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Type of Casing-0 _ Specifications f l ❑ Domestic/Private Q4 Gravel Pack ❑ Tracy yp �y dJ ❑ Other bQ Delta Depth of Grout Seal Z Type of Grout p 1"1 Public I I Irrigation Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done U Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 50'1 -- TYPE OF SEPTIC WORK: NEW INSTALLATION 1 I REPAIR/ADDITION l I DESTRUCTION I I (No septic system m rented if public sewer is Installation will serve: Residence_ Commercial_ Other 01 Number of living units: Number of bedrooms Water table depth Character of soil to a depth of 3 feet: SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments Method of Disposal PKG. TREATMENT PLT. ❑ Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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 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." The applicant must call for allreq lred i spec ions. Complete drawing on reverse side. � '� ��' Title:��•"' �-' Date: Signed X .1 —s OR TMENT USE ONLY 2 2 Date rea J/ - Application Accepted by ' /� Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: /,W/ ❑ Stk 466-6781 ❑ Lod' -3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return at c nvironme al Health Pe 1t/ rvlces 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE K RECEIVED BY DATE PERMIT'NO. INFO AMOUNT DUE AMOUNT REMITTED H . EH 13-24(REV.1/x 5) d (� �j' O'`O EH 14-2A