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in i E E APPLICATION FOR PERMIT ' ° SAN JOAQUIN LOCAL HEALTH DISTRICT NOV 1 1601 E. HAZETON AVE., STOCKTON, CA Telephone (209) 466-6781 ENVIRONMENTAL. HEALTH I PERMIT EXPIRES 1 YEAR FROM DATE ISSUED PERMIT/SERVICES (Complete in Triplicate) nstall the work herein described. This is cation Application is hema a tothe San Jo Joaquin County Olydinalnce No. 549 for sewage or permit No. 1862 fo construct and/or Health District for a we 1lpumlP and the Rules and Regulations of the Sanl Joaquin made in compliance with Local Health District. �� ' PM h City Lat Size Job Address -760ty /� � Phone t Owner's Name t✓ Address � Contractor�-�,pn LKL. Address 5f Ea'rp— S G14-�ln Com.gs24�License No. t 7�Zla�Phone WELL REPLACEMENT F1 DESTRUCTION ❑ /1#oi+ljft q TYPE OF WELLIPUMP: NEW WELL LlWELL REPAIR ❑ OTHER Spy / bo/2/N/`3 PUMP INSTALLATION Ll SEWER LINES DISPOSAL FLD. PROP. LINE �,� DISTANCE TO NEAREST: SEPTIC TANK yea �a I OTHER WELL PITS/SUMPS �" l FOUNDATION AGRICULTURE WELL �l�b ti ' INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS rl Dia. of Well Casing ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavali�� L` — T e of Casin c P Specifications ❑ Domestic/Private 17 Gravel Pack © Tracy Type g—�' --T'a,T' �� Type of Graut�'Q/�.P�--. F1 Public }rQ Other F1 Delta Depth of Grout Seal ' 1 1 Irrigation Approx. Depth I I Eastern Surface Seal Installed by �r- H p State Work Done Repair Work Done ❑ Type of Pump Sealing Material (top 50') f Well Destruction ❑ Well Diameter Depth Filler Material [Below 50'1 TYPE OF SEPTIC WORK. NEW INSTALLATION 1.1 REPAIR/ADDITION I I DESTRUCTION I I aNailabpefwithine200 feetm pe .) if public sewer is Installation will serve: Residence— Commercial— Other r Number of living units: Number of bedrooms Water table depth Character of soil to a depth of 3 feet: Capacity No. Compartments SEPTIC TANK ❑ Type/Mfg Method of Disposal PKG. TREATMENT PLT. ❑ t l 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 l 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 I rules and regulations of the San Joaquin Local Health District. Home owner or licensed agent's signature certifies the following: "1 certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner n 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 E tion laws of Cali ia." The applica m t�call for II required ' pe ns. Complete drawing on revside. + Title: Signed X Date: `! FO EPAT NT USE ONLY / /� r- r Date // a Application Accepted by Date Final Inspection Pit or Grout Inspection by Date 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, Silk- CA 95201 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO tr +.EH 13-24(REV.i i n 5Y a] R