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„ f l ' y APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZETON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) application is /or install the work esc Application is hereby made to the San Joaquin LocalHealth Nto.549 for sewage or permit No. 1862 forcwell/dpump and theft les and herein R Regulations of the San Joaquin made in compliance with San Joaquin County Ordinance .4L Local Health District. i T/ S'o w 4 ��UT QU - CitLot Size — PM I Y�L/ � A y r Job Addressxlkd✓? G S,O /_iA�� lid/ Phone Address W�n1 NA'bla� , Owner's Name 1 � /� v�Ia ` O �73, Phon 37T� >�f�,�ani Address License No. Contractor �� DESTRUCTION NEW WELL WELL REPLACEMENT ❑ PUMP INSTALLATION ""� `"`'SYSTEM AIR ❑ REPOTHER C1TYPE OF WELL/PUMP: c- \ DISTANCE TO NEAREST: SEPTIC TANK �Qi�— SEWER LINES ��— DISPOSAL FLD. PROP. LINE 4 PITS/SUMPS FOUNDATION AGRICULTURE WELL OTHER WELL � 1 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Specifications Domestic/Private Type of Casing [Gravel Pack- L3 Tracy YP iS _ {1 Cl t=1 Other Delta Depth of Grout Seal S� r �e of Grout Public ADepth l I Eastern Surface Sea! Installed by I 1 Irrigation — pprox. - f Sta Work Do+ Type o1 Pump � H.P. Repair Work.Done T i� TYP �l(/ Sealing Material (top 501 Well Destruction Well Diameter Filler Material {Below 50') Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I.1 REPAIRlADDITION l 1 DESTRUCTION I i availablleseptic wthin 200 feet.) if Public sewer 's ) i l Installation will sive: Residence— Commercial— Other Number of living units: Number of bedrooms Water table depth Character of soil'fo a depth of 3 feet: N. Compartments t Gapacity k «SEPTIC TANK r❑ ' TypelMfg Method of Disposal PYG. TREATMENTIPLT. ❑ Property Line ` Distance to nearest: Well Foundation I Total length/size LEACHING LINE ❑ .r No. & Length of lines Property Line FILTER BED ❑ Distance to nearest: Well Foundation p rtY- Number SEEPAGE PITS I } Depth Size Property Line SUMPS Ll Distance to nearest: Well Foundation P Y 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, an rules and regulations of the San Joaquin Local Health District. ormance of the work for which this permit is issued, Home owner or licensed agent's signature certifies the following: "I certify that in the perfI she no employ any person in such manner as to become subject to workman's compensation laws of California.” Contractors 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 parsons subject to workman's compensa- tion laws of California." The applicant must call for all requir d inspections. Complete drawing on reverse side. -2 Title: OL Date: Signed FOR DEPARTMENT USE ONLY l Date Area 121 Application Accepted by I Final Inspection by ,/ Date `'� ft Pit or ro Inspection by . Date i _-� ✓ F Additional Comments- 835- CJ Stk 466-6781 ❑ Lodi 369 ironmental Health Perm-3621 Li Mani.Lat I�nri e0s 1601 E❑T aly 38 P.O. Box 2009, Stk., CA 9520 5 Applicant - Return all copies to. Env01/l FEE RECEIVED BY DATE PERMIT NO. AMOUNT DUE AMOUNT REMITTED SH INFO ]f + EH 13-24 TREY.r 51 EH 14-26