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• APPLICATION FOR PERMIT 0 SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) n described. This application is t and/or work he made nticcomplliance with made SanoJoaquin County Ordinathe San Joaquin Localnce No.549 for sewage or Health District for a permit Noo 1862 for cwell/pump install nd the Rul s and IRegulations of the San Joaquin Local Health District. �f_ City Lot Size PM Job Address - Address 9^^ 2c. Phone Owner's Name Address WELL REPLLicense No - Phone Contractor AGEMENT Cl❑ DESTRUCTION ElyvJeC�-tOy� TYPE OF WELL/PUMP: NEW WELL El OTHER Q -- , PUMP INSTALLATION F1SYSTEM REPAIR 11 _ 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 Dia. of Well Casing ,3 ❑ Industrial ❑ Open Bottom ❑'Manteca Dia. of Well Excavation l -, )- Specifications ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing fl Delta Depth of Grout Seal -- Type of Grout — f-1 Public _ (7 Other A rox. Depth I Eastern Surface Seal Installed by I I Irrigation — pp State Work Done _ Repair Work Done L] Type of Pump H.P. Well Destruction ❑ Well Diameter Sealing Material (top 501 -" Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I REPAIR/ADDITION I I DESTRUCTION I 1 septic within 20 l0 feet.) ed it public sewer is available Installation will serve: Residence_ Commercial_ Other Number of living units: ._ Number of bedrooms Water table depth Character of soil to a depth of 3 feet: r��a� SEPTIC TANK ❑ Type/Mfg Capacity No. d'7!t't�sDs Met o f� II PKG. TREATMENT PLT. ❑ Distance to nearest: Well Foundation Property LFW—y=.z.-1F-G® LEACHING LINE ❑ No. & Length of lines Total length/size Foundation AQUIN C UNTY FILTER BED ❑ Distance to nearest: Well Propp/1q, VICES SEEPAGE PITS 11 Depth Size Number Y1JC�� SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 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 Di3trict. 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 all required inspections. Complete drawing on reverse side. n n _ Signed .�� I q ��0 Title: Date: FOR DEPARTMENT USE ONLY c— r1.L -dDate 3 Area Application Accepted by nL.�/„t,.-c.�ily �/��' � s' Date Pit or Grout Inspection by Date Final Inspection by Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ 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 CK RECEIVED BV DATF PERMIT NO. AMOUNT�.D(U�E/ A�11MINI REMITTED 1 CASH FOL e.EN 13-24 IREY.1/x 51 EH N-m