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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELT ON AVE., STOCKTON, CA Telephone (209) 466-6781 ► PERMIT EXPIRES TYEAR FROM DATE ISSUED , (Complete in Triplicate) application s' 649 for sewage or No. 1B62 for welllpump and the Rules and Regulations of the San Joaquin Application is haleby made to the San Joaquin LocaVnCeea�o District rict for a permit to construct and/or install the work herein described. This App uin County Ordinance made in compliance with San Joaq Local Health District. PM h City Lot Size k 0 �+ Job Address Phone �„-- I Owner's Name License No. Phone I Eu ( Address _ Contractor__4LWELL•REPLACEMENT- ❑ , .. DESTRUCTION_©_ Y r= IVEW-WEL-L-.O-. .Y w= OTHER ❑ a.a.._ YTYP€ OF�WELL-/-PUMR. - � SYSTEM REPAIR ❑ PUMP INSTALLATION ❑ _ 'DISPOSAL FL"D=_'n `�"""-PROP'A:INE"'"'" '� IY�T- - - SEWER LINES'— -- PITS/SUMPS 1 DISTANCE TO NEAREST: SEPTiG TANK— AGRICULTURE WELL OTHER WELL- --------- ELL—FOUNDATION TENDER USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS` Dia of Well Casing IN ❑ Manteca - Dia. of Well Excavation ❑ Industrial ❑ Open Bottom - `' Specifications ; ❑ Tracy _ Type of Casing ❑ Domestic I private L1 Gravel Pack i 171 Delta _Depth of Grout Seal Type of Grout --�— i`l Public n Other* _ - Surface Seal Installed by I I Irrigation �..Approx. Depth�_ i I Eastern i I State Work Done _ H.P-: Repair Work Done ❑ Type of Pump Sealing Material (top 50') S Well Destruction ❑ Well i7iametEr— _... " Depth Filler.,Material (Below 50'1 ermined if public sewer is p I F` available within 200 feet.) TYPE OF SEPTIC WORK: cNE1N INSTALLATION i:! REPAIFl1ADDiTION ESTRUCTION l"I.a septic system p Other installation Installation will serve: Residence Commercial Number of bedrooms 1 l Number of living units Water table depth h Character of soil to a depth of 3 feet: - Capacity — Nb�'Compartments I SEPTIC TANK ❑ Type/Mfg Methodsol Disposal Q PKG. TREATMENT PLT. ❑ Foundation Property Line Distance to nearest: Well _ Total length/size LEACHING LINE No. & Length of lines � I property Line Foundation FILTER BED ❑ Distance to nearest-'" Well Size .Number } SEEPAGE PUTS f I Depth t Property Line ' s Foundation p rtY (' SUMPS ❑ Distance to nearest: Well DISPOSAL PONDS ❑ ' 1 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.g y Home owner or licensed agent's signature certifies-the followin I certify that in the performance of the work for which this permit is issued, l shall not hiring.11 Contractor's s of California sub-contracting signature employ any.persovnsuc�rtftht subject sceseion ikman'sompensa ts issued,I halizemploy persons subject to wor certifies the following: y e in the performance ha work fowhihhs perm ' ' } tion laws of California." �, The applicant must call for all required inspections. Complete drawing on reverse side. Y .. Title: Date: Signed X Adjol''oll,'' bjk____ �,Rl PARTMENT USE ONLY �� O Date Area k Application Accepted byrfitJ a Date_- Fina1 Inspection by ' �. . . Pit of Grout Inspection by Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 O Tracy �5 2009, Stk:; CA 95201 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box CK RECEIVED BY DATE PERMIT NO- r FEE AMOUNT DUE AMOUNT REMITTED CASH INFO + EH 13.24(REV.t/k 51 EH 14-2e -