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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL I ON AVE., STOCKTON, CA A7 Telephone (209) 466-6781 4 ' PERMIT EXPIRES 1 YEAR FF�OM DATE ISSUE „ (Complete in Triplicate) work herein described.This application is or No.1862 for well/pump and the Rules and Regulations of the San Joaquin Application is hereby made to the San Joaquin Local He It 549 for sewage District for a permit to construct and/or install the made in compliance with San Joaquin County Ordinance Local Health District. .q: 'AC C_ Lot Size_16 — PM �j f 6 t City . Job Address - Phone aS Address Owner's Name Phone ' License No. i E Contractor's Name WELL REPLACEMENT ❑ DESTRUCTION ❑ NE1N WELL 0 '•? i TYPE OF WELLIPUMP: i -, �- � OTHER-❑" -' a PUMP INSTALLATION amt--SYSTEM-REPAIR ❑ PROP. LINE ER LINES SEW _�--� DISPOSAL FLD. DISTANCE TO NEAREST: SEPTIC TANK �— OTHER WELL— INTENDED �- FOUNDATION ��- AGRICULTURE WELL r IPROBLEM _ INTENDED USE TYPE OF WELL AREA CONSTRUCTION SPECIFICATIONS Dia of Well Casing ❑ Ode g E7_Manteca Dia. of Well Excavation—^�-- ❑ industrial Specifications ❑ Tracy Type of Casing ❑ Domestic/Private Q Gravel Pack type of Grout ❑ Other ❑ Delta Depth of Grout Seal r ❑ Public Surface Seal Installed i ❑ Irrigation ___Approx. Depth ❑ Eastern state Work Done H.P. Repair Work Done ED Type of Pump �� Sealing Material Itop 501 ti Well Destruction ❑ Well Diameter Filler Material {Below 501 'S.r t '' Depth b withirj.200 feet.) I - i TYPE OF SEPTIC WORK; NEW INSTALLATION REPAIRIADDITION�C] DESTRUCTION ❑ (No septic system-permitted if public�s availableewer�isy fr' Installation will serye Residence Commercial.- 44 Other�_Q -'�— - - :; ; .,; Nmber o uf bedrooms "~ Number of living units: n Water table depth I Character of soil to a depth of 3 feet: �D No. Compartments SEPTIC TANK ❑ ,Type./Mfg P' L� �V1—� ' -` Capacity Method of Disposal r ._P-KG.TREATMENT PLT. ❑ I Property Line Distance to nearest: Well Foundation t # Total length/size I , y LEACHING LINE F3 No. & Length of lines property Line T Distance to nearest: Well Foundation ! # FILTER BED ; i bSlze Number t SEEPAGE PITS ❑ Depth Property Line f } SUMPS [IDistance to nearest: Well Foundation -- 4* , DISPOSAL PONDS ❑ �. - :,r. � I hereby certify that l have Prepared thisaLocal HI ealth p stalcthe work will be done in accordance with San Joaquin county,ordinances;state laws, an fk} rules and regulations of the San Joaquing: "I ce i i"Home owner or licensed agent's signature certifiesthe f ub ect lto wrorkman's compensation lrtify that in the awsoof Califo�n'a. Cont actof the work for r slh ging:och this p sub cont act ngermit is l signlatuaa s employ any person in such manner-as�to-becomes 1 rsons subject to workman's compensa- certifies the following:"i certify that in the performance of the work for which this permit is issued,I shall employ pe 1 r 4 tion laws of California." �- omplete drawing on reverse side. i The applicant must call f all r uired inspections. C ----` - Date Title: .FORrDEPA�tTMENC._1UNC _ Area ! l Date 1 Application Accepted by =p Q=.-- i,:. Date Final Inspection by Pit or Grout Inspection by - its n ,•.t_� .+ Ad itlonsl Comments. '' �;,' , ❑Tracy 8356385 O� tk 466&781 t❑ Lodi ��64 3621 ❑ IVFariteca �87,i 71D4 g •. Applicant:Return all coples_,to: Env'I�ronmental Health-Pe rmit/.Services 1601E Hazelton Ave P 0 Box 2009;Stf�c CA��2D +� �q , ti '",. r•' * ` CK DATE }PERMYT'N0 � - s'.„ ^RECEiVED�BY �` FEE AMOUNT DUES AMOUNT REMITTED CAS INFO _ ` - .,u p 1.k A•i.. T' �M. �.. L + EH t3-24IREV.101831 ��._, „�. �,�, ti -. - k EK 1428