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APPLICATION FOR PERMIT a SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1'YEAR FROM DATE ISSUED (Complete in Triplicate) 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 made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Locai Health District. Job Address 13091 S. WILLQI GLEN ROAD City STOCKTON Lot Size PM Owner's Name NANCY MUHS Address 13091 S. WILLOW GLEN RD, STKN, *§9Q6 465-9859 p Contractor NOACK PUPOMPA Y Address 5 0 E RE License No. 504513 Phone_948-8817 r TYPE OF WELL/PUMP: NEW WELL ❑ WELL!REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION IJQ SYSTEM REPAIR ❑ OTHER ❑ j DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE a FOUNDATION AGRICULTURE WELL �" OTHER WELL PITS/SUMPS INTENDED USE + TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS f r - ii ❑ Industrial ❑ Open'Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing i "Domestic/Private ~.x .❑ Gravel Pack ❑ Tracy Type of Casing' Specifications (1 Public r ❑ Other f 11 Delta Depth of Grout Seat Type of Grout I i'Irrigation- 'R" - _.-Approx. Depth•...„.1-1-Eastern_Surfa a-Seal lnstalled.by Repair Work Done +'[7 r Type of Pump SUBMERSIBLE.P. 1-45 HP state Work Done REPLACE JET PUMP Well Destruction k❑F well Diameter Sealing Material Itop 50'1 WITH SUBMERSIBLE PUMP —' Depth I Filler Material lBelow 50') — 0 TYPE OF SEPTIC WORK: NEW INSTALLATION I] REPAIR/ADDITION I I DESTRUCTION-I,I {No septic system permitted it public sewer is � available within 200 feet.) *` Installation will serve: Residence. Commercial— Other °i V Number of living units: Number of bedrooms } Character of soil cola depth of 3 feet:) Water table depth I (1/}{ SEPTIC TANK. 5 #• t ElType/Mfg Capacity No. Compartments � �1 PKG. TREATMENT PLT. ❑ I Method of Disposal ti Distance to nearest: Well Foundation Property Line Q_ ) Q LEACHING LINE rr ❑ No. & Length of lines Total length/size o FILTER BED ❑ Distance to nearest: Well Foundation Property Line • SEEPAGE PITS l I Depth I Size Number,- r ' SUMPS L1 Distance to nearest: Well_ Foundation - Property-Line--. i DISPOSAL PONDS ❑ 4 I 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 Diktrict. r Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as 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 perfor ance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of Gal- rnia."' The applicant m st c II fo all equ' i ns. Complete drawing on reverse side. 1 Signed x Title: SALES/SERVICE Date: �2 APRIL 1990 FOR DEPARTMENT USE ONLY qq ] Application Accepted by Date L rea 1 Pit or Grout Inspection by Date Final Inspection b;79�_7 _y U Date ' r Additional Comments: Y ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 " Applicant- Return ail copies to: Envirorimentel Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201, y � ..r FEE INFO AMOUNT DUE I AMOUNT REMITTED CASH K 41 RECEIVED BY DATE PERMIT'NO. `1 r.EH 13-24(REV.1/n5) �` y/�ry h'0-75� I EH,1 4-2e J •4