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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT . 1601 E. .HAZEL i ON AVE., STOCKTON, CA Telephone (209) 466-6781 t. PERMIT EXPIRES 1 YEAR FROM,DATE ISSUED (Complete in.Triplicate) s� Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is F or No. 1862 for we11/pump and the Rules and Regulations of the San Joaquin made in compliance with San Joaquin County Ordinance No.549 for sewage Local Health District. City 7� +r/ Lot Size PM Job Address -3, W' I d ' S T Phone Owner's Name G� c' , Address s Contractor EL-0 'E' !•fI, Address ',tl, tet. A.1/ S License No.�>� Y7 Phone TYPE OF r ELL(PUMP: NEW WELL LJ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION E] r SYSTEM REPAIR ElOTHER ❑ DISPOSAL FLO. DISTANCE TO NEAREST: SEPTIC TANK` SEWER LINES PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL—PITS/SUMPS , INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing 1 ❑ Industrial 11 Open Bottom ❑.Manteca t Dia. of Well Excavation ` Type of Casing Specifications ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy t T e of Grout ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type ❑ Irrigation �4pprox. Depth ❑ Eastern r Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P..` State Work Done_ 4� Well Destruction ❑ ,,Well Diameter Sealing Material [top 50'i I" Depth I Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INS'�ALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septilable system permitted if public sewer is Installation will serve: Residence—"Commercial Other Number of living units: Number of bedrooms �3.-- ' Water table depth Ili Character of soil to a depthh of 3 feet: YP A f Compartments SEPTIC:TANK T e/Mfg e - �— y�'*ICapacityl No.— s Method of Disposal PKG. TREATMENT PLT. ❑ 1 F +` p P rty Line Distance to nearest: Well IV A Foundationl I Lc- . A g� �YTbial-length ' 761 i.v LEACHING LINE C� No. & Length of lines y — r i FILTER BED Ll to nearest: Well Foundation -7�4=' Property Line � SEEPAGE PITS ❑ epth �D Size y t !Number t '� r SUMPS U9' Distance to nearest: Well 1A Foundation /m4 i Property Line DISPOSAL PONDS ❑ s 4 " dance with San Joaquin county ordinances, state laws, and 1 hereby certify that I have prepared this application and that the work will be done in accor rules and regulations of the San Joaquin Local Health District. M fy that in the performance of the work for which this permit is issued, I shall not Home owner or licensed agent's signature certifies the following: "I card employ any person,in such;manner.as'Ft6,6ecome subject to workman's compensation laws of.California."Contractosonslsubject t wo�kman'1scompensa I certifies the following: "I certify that in.the performance of the work for which this permit is issued;f'-shall employ p f tion laws of California r, The applicant must call for all required inspection . Complete drawing on reverse side. . I Title: 1. ,0- ° Date: l� . Signed ' FOR DEPARTMENT USE ONLY" , // V Date Z T—f[7� Area 4 Application Accepted by Pit or Grout Inspection by act- Date Final Inspection by__ y -- Dat ,f Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 C] Manteca '823-7104 ❑ Tracy 835 G3$5 I Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.Q. Box 2009, Stk., CA 95201 CK I FEE AMOUNT DUE AMOUNT REMITTE❑ GASH RECEIVED 9Y DATE PERM47 NO. INFO — --��i- f + EH 13-24(REV.1 i B 5) �� >- EH 14-26