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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL-HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466.6781 SCANNED PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a made in compliance with San Joaquin County Ordinance No.549 for sewage No. 1861 for it to c well pandlump and the ales and Regulations o{the pan Joaquin Local Health District. or install the work herein application n Job Address 3' c''�Y% 1L1� �G�i f City nef� Lot Size x PM FOwner's Name /Yh I fiA5/J y 61' Address .Z 5 �-k, C7 C`d,WC&7 e/ CAR. _ Phone Contractor r OH <VXIAddress /47 gQ/1;7-0 TYPE OF WELL/PUMP; f icense No. •y �9 Phone 4. NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ t ,A PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ DiSTANCE TO NEAREST: SEPTIC TANK OTHER ❑ # SEWER LINES OTHER FLD, f�� - •' --• '- T FOUNDATION PROP. LINE �ArR1r11LTURE WELL OTHER WELD-....� . INTENDED USE PITS/SUMPS TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS # 13 Industrial ❑ Open Bottom ❑ Manteca ❑ Domestic/Private ❑ Gravel Pack Dia. of Well Excavation Dia. of Well Casing ❑ Tracy El Public of Casing Public k ❑ Other Type g Spec cations ` EJ Irrigation , Depth of Grout Seal F 3 ---Approx. Depth EJ Eastern Surface Seal Installed by T °f Grout_ ! Repair Work Done ❑ Type of Pump * Well Destruction C1 Well Diameter H P State Work Done Sealing Material {top 50'} 1J" I ° Depth Filler Material (Below 501) x? TYPE OF SEPTIC WORK; NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑ INo septic system 1" permitted if Public Installation will'serve: Residence p sewer is available within 200 feet.} y' L Commercial Other��_ Number of living units:L_ Number of bedrooms -7 Character of soiFto a depth.of 3 feet: .4 L o M+ Water table depth 1A.17 SEPTIC TANK .2Type/Mfg P Gy n PKG. TREATMENT PLT. ❑ Capacity--1 A CO No. Compartments ±-2- t/ ` ? Y Distance to nearest: Well Foundation 0 Method of Disposal Property Line LEACHING LINE No. & Len th of lines. A &C- FILTER BED ❑ ^Distance to nearest: Well /fid ' Total length/size Y Foundation /_ /�_ Property Line S`� 14 SEEPAGE.PITS ❑ Depthr SUMPS Size-LRlar /�� - +" Number Line � Distance to nearest::. Well 1 DISPOSAL PONDS ❑ K `Foundation r7o Property Lin ! ! 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., { employ any person g such manner as to become subject to workman's compensation lawsoof California."rmance Contractofor r,tots hiring o sI'mit is ub-cant sued, Isignaltnot certifies the following: "I certify that in the performance of the work for which this tion laws of California." +,, permit is issued,1 shall employ persons subiect to workman's compensa- rThe applicant must call for all required#inspections. Complete drawing on reverse side. ; Signed - :� er t--^�[ -. r ,.. - Date: c ' R m ARTMENT USE ONLY Application Accepted by / Pit or Grout Inspection by. ` Date Area fir` / Date R I Inspection by S� Additional Comments: i_ Date ❑ Stk 466-6781 ❑ Lodi 369-3621 - ❑ Manteca , 7104 ❑ Tracy 835-6385 , l tApplicant Return.all copies to 21 Permit/Services 1601 E:Hazelton Ave., P:O. Box 2009, Stli: CA 95201 x < + *� _ b FEE AMOUNT DUE j INFO AMOUNT REMITTED CK RECEIVED BY DATE P -- ✓i ERMIT''N0. + EH 13-241REV,f/a5) `� EH 7428 /o Q t