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APPLICATION FOR PERMIT SAN JOAOUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone QD91 466-6781 F PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) erein .This ll the work In Application is hereby made to the Joaquin aqunty ordinance cation is in Local e No.549 for for or permit 1862 for well//pump and the Rules and Regulations of the Soman'Joaquin made in compliance with San J q Local Health District. p � D PM ! 1 Z Q 4 ry� O✓ G( G lL City �fieo Lot Size ! 2 Job Address r f 432_y -Z y9 '} ., V Phone ail Address MM.,.. . .,� -. Owner's Name _. Y .. gz.3;� 4f elX r ' Phone l e( t'et /? C Ape AddressLicense'No`_ ^�--- Contractor DESTRUCTION ❑ l NEW WELL WELL REPLACEMENT ❑ TYPE OF WELL/PUMP: �F SYSTEM REPAIR © OTHER ❑ 'PUMP INSTALLATION ❑ SEWER LINES DISPOSAL FLD. PROP. LINE DISTANCE TO NEAREST: SEPTIC TANK PITS/SUMPS FOUNDATION AGRICULTURE WELL OTHER WELL f INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing Dia. of Well Excavati ❑ Industrial ❑ Open Bottom ❑ Manteca on Specifications ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing ` IE ❑ Delta Depth of Grout Seal Type of Grout D Public ❑ Other ❑ Irrigation 1(`, Vii! —.—Approx. Depth ❑ Eastern Surface Seal Installed by 't. State Work Done H.P. Repair Work.Done. ❑ Type of Pump+_�— Well Destruction [3 Well Diameter Sealing Material (top=50,) k, t 31 Filler Material )) -(Below-50' �•' Depth TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION [3 DESTRUCTION❑`availabllelwth n, feettted if public sewer is Installation will serve: Residence— Commercial Number of living units: _J_ Number of bedrooms a• -�� B o s. Water table-depth Character of soil to a depth of 3 feet: gr. 2 - C pacity O� �rd�No. Compartments r SEPTIC TANK Type/Mfg �a� , { ."! Method;of Disposal; PKG. TREATMENT PLT. ❑ t _f, ' . r -�. w: ' ' 4D ' ' Foundation r. Property Line-" +s Distance to nearest: Well :�-• �- � F r j* No. & Length of.1ines Total length/size LEACHING LINE _ Property Liner# F FILTER BED 11 Distance to nearest: i Well _ Foundation P rtY — i'.Z i I SEEPAGE PITS C7 Depth Size Number Foundation�:-�—,Property SUMPS ❑ Distance to nearest: Well �-, �► , 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 rules and regulations of the San Joaquin Local Health District. , Home owner or licensed agent's signature certifies the following: "I certify that'ih.the.:performdnce of the work for which tf►is,permit=is issued„I shalt-not employ any person in such manner as to become subject to workman's cornpensa-fl Iowa of California.”Contractors Wring or sub contracting signature certifles`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 Jcompansa tion'laws'of California." `�A /1 / 7 The applicant must call for all required inspections. Complete drawing on reverse=side f:Titlei� O h v Date: Signed s '-.-"FOR DEPARTMENT USE ONLY Ile Date��/� M �� Area �-� 7f Application Accepted by III —Date Pit or Grout Inspection by Date Final Inspection by Additional Comments: ~ ❑ Stk 466-6781 El Lodi;- 36.9-3621 ❑ Manteca lton Ave., P.O.23 7104 El 835e., P. Box 2009, Stk., CA 9 5201 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Haze CK RECEIVED BY DATE PERMIT MO. IFEE NFO AMOUNT)DUE AMOUNT REMITTED REV.5/B 5} rI �. � / � + EH 13.241 ��•ri EH 1426