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r r APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) t and/or.install the work catioh is Application is hereby with San joaqu n County Ordinance No.D549 for sewage or permit No. 1862 forcwell/pump and the Rul s and hereinR gulations of the San l Joaquin made in compliance Local Health District. 7.x f/ a Lot Size f9 PM G 3 Job Address �y L �� e �T !I CityG�BDfl B7!gyp aV / ( ( Phone Owner's Name l Address 1 Contractor's Name License No. Phone C s OF WELL/PUMP:E NEW WELL �.. . r �, WELL REPLACEMENT ❑ DESTRUCTION 11TYP *.� s 1. SYSTEMAEPAIR LI - OTHER-L1 PUMP INSTALLATION, tp \ PROP. LINE TO EA . :-S—- SEWER LINES DISPOSAL FLD. { DISTANCE'TO NEAREST: SEPTIC TANK _ __ - _ . _ - �----•--- k FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS 7 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Specifications k I Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ 1 L1- �L _.._ I 1 Depth of Grout Seal FT, Type of Grout Q e ❑ Public ❑ Other ❑ Delta 1 0 %y El Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by ISOd � _ H.P. —�� State Work Done OU Repair Work Done ❑ Type of Pump r Well Destruction ❑ Well Diameter �7 Sealing Material Itop 501 er f Depth r_ 0 ' Filler-Material-(Below-50'.) TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic sy tem rmitlted if public sewer is avaInstallation will serve: Residence— Commercial Other w Number of living units: Number of bedrooms ti t _Water table depth Character of soil to a depth ofi fees:. - - No. Compartments SEPTIC TANK TANK ❑ Type/Mfg Capacity Method of Disposal + PKG. TREATMENT PLT. El �-� I Distance to nearest: Well Foundation. Li Property ne � �__._.� •�+ � �-`� Totallengthlsize LEACHING LINE ❑ No. & Length of lines - FILTER BED El Distance to nearest: Well Foundation Property Line i SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ hereby certify that l have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and j rules and regulations of the San Joaquin Local Health District. C rtify 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 ce compensation laws of California."Contractors hiring or sub-contracting signature employ any person in such manner as to become subject to workman's certifies 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 compensa tion laws of California." The applicant st call forIrequired i pections. Complete drawing on reverse side. Zp t1�� Title: �` g Date: l Signed 1C �� 091FOR DEPARTMENT USE ONLY Data / �y~� Area 12— Application 2— Application Accepted by ��`• Pit or Grout Inspection by Date '� Final Inspection by Date 99g5� Additional Comments: [2 Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-63E35 r Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 k FEE CK RECEIVED BY DATE PERMIT'NO. INFO AMOUNT DUE AMDUNT REMITTED GASH —� + EH 1324 IREV.101831 FT U O cu i7N