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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA M' _ '�{ r�•' ii1 Telephone (209) 466-6781' ^` PERMIT EXPIRES 1-YEAR FROM DATE ISSUED f '' (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 e or No. 1862 for woupump and the Rules and Regulations of the San Joaquin made in compliance with San Joaquin County Ordinance No.549 for sewag Local Health District. t 2-- / 0�6 `S, � _ f�R.�PCy - Lot Size 1' PM �� i Job Address • F, t Q 415- 54 � C,� Phon Address _ r X Owner's Name`' Address '7 [ S2 t - License No. Phone Contractor _ NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ TYPE OF WELL/PUMP: - # PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ " OTHER ❑ ; D�- SEWER LINES _—a/ DISPOSAL FLD. �(Z 'PROP. LINE P TO NEAREST: SEPTIC TANK SE D157ANCf OTHER WELL .� PITS/SUMPS � f^ k FOUNDATION _ AGRICULTURE WELL ` INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing El Industrial 'Open Bottom ❑ Manteca Dia. of Wel! Excavation r T e of Casing Specifications 1� omestic/Private ❑ Gravel Pack Q Tracy YP g Type of Grout_.��- ❑ Public f_-} Other Ll Delta Depth of Grout Seal - - I 1 Irrigation ( Approx. Depth I I Eastern Surface Seal installed by S H.P. State W one_ Repair Work Done ❑ Type of Pump t Well Destruction 1 ❑ Well D-I eter Sealing Material [top 50') t t De -Sealing Material (Below 501 OF SEPTIC'WORK: NEW INSTALLATION 1.1 REPAIRlADDITION 1.1 DESTRUCTION I I alvailablleseptrc system w thin 200 feet. f public sewer-is- TYPE 9 4 W jnstallation will 11 Residence— Commercial Other' -Number of living units: Number of bedrooms Water table depth ' wCha acter of soil to a depth of 3 feet: Capacity j. SEPTIC TANK .' ❑' Type/Mfg No. Compartments Method of Disposal PKG. TREATMENT PLT: ❑ �1 Distance to nearest: Well Foundation Property Line Total length/size LEACHING LINE 1 ti C1 No. 8r Length of lines I FILTER BED ❑ Dstance,to nearest: Well Li", Foundation Property Line z v'l# " SEEPAGE PITS l If Depth Siz _wiVumber � -.ti-. ..�.. ,- - Property Line t"- SUMPS fLl Distance to nearest. ell Foundation p rflr �Yc 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. [ "1 l I owner or licensed agent's signature certifies the following: "I certify that in the performance of,the work for which this permit is issued, 1 shall not ,k--Home r_HomeHome -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:amplo� certify that s the performance of the work for which this permit is issued. I shall emp}by persons'subject to workman's compensa="' tion laws of Caltorri 1 The applicant mu for all required inspections mplete drawing on reverse side. i r Title: Date: Signed X f ! t> ' F FOR DEPARTMENT USE ONLY -� r t Date. a- - Area A ation Accepted by ,.✓ >r� �wy Date. 2� Date ~ Final,Inspection by_ Pit Grou nspection by .rt _ _ .... r AV Additional Comments: T ` - : ❑ Stk 466-6781 C1 Lodi 1369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 �,9 J� ,.xApplican[_-_Return all copies to. Environmental-Health Permit/Seryices 1601 E:Hazelton Ave., P.O:Box 2009, Stk.;CA 95201 t FEE CK RECEIVED BY DATE PERMIT'NO. INFO AMOUNT DUE AMOUNT REMITTED CA H Mgr ♦ EH 13-24)REV.1/85) •EH t4-26