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APPLICATION FOR PERMIT SAN JOAQUIN LOCAV HEALTH DISTRICT 1601 E. HAZEL—i ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED r ` in"Tri ficate} II {Complete p ,.....4 -t.. Application is hereby made t 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 well/pump and the Rgles and Regulations of the San.Joaquin made in compliance with San Joaquin County Ordinance No.549 for sewag ,iLocal Health District. • �* � � +s ,, v 3 G��y Linden • 'Lot Size ` ' ' PM ' Job Address 7474 N. Cox ; a. FV Owner's Name Catherine Canepa Address 7474 N. COXt Linden, CA. - Phone..887-3653 Contractor IIGM061"n9ontldress P. O. Box 64 _License No.377923 Phone887-3554 TYPE OF WELL/PUMP: NEW WELL C3 WELL REPLACEMENT ❑ DESTRUCTION 171 PUMP INSTALLATION 11 SYSTEM REPAIR 11OTHER We11 repair ' DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE I { _ FOUNDATION,. AGRICULTURE WELL OTHER WELL PITS/SUMPS_ E INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION-SPECIFICATIONS 4 ❑ Industrial x] Open Bottom El Manteca Dia. of Well Excavation Dia. of Well casing Casing ea X Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Steel Specifications t C3 Public ❑ Other [1 Delta Depth of Grout Seal 90 , Type of Grout i+ ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by t Repair Work Done ❑ Type of Pump H.P. IState Work Done J Well Destruction ❑ Well Diameter Sealing Material (top 5D'} J 1 Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIRIADDITION LJ DESTRUCTION ❑ (No septic system permitted if public sewer is S available.within 200 feet.( Installation will serve: Residence Commercial_ Other v Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance.to,nee rest: Well -Foundation - _ �- ,Property,•Line lTotal length/size LEACHING LINE ❑ No. & Length of lines ` i FILTER BED ❑ Distance to nearest: Well Foundation Property Line I - SEEPAGE PITS- El Depth Size Number ' SUMPS17Distance to nearest: well Foundation Property Line _ .,.,. .�:�-a ,.:-- .. ,.� •�-per.=-_-^m--••�.w� ------,�-,�-,..,..--�- ,-..-_--�.�-�.- ,. - ,: 'SPOSAL 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 i rules and regulations of the San Joaquin Local Health District. : "I certify 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 pensationllaws of California." Contractors hiring or sub contracting signature employ any person in such manner as to become subject to workman's com 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." ;'� A Iov The }cant t call for re 'red inspections. Complete drawing on reverse side. Sign Title: COrT3: Secreta, Date: 12/19/86 1� DEPARTMENT USE ONLY „ Application Accepted b Date Area A W ' Y Date Final Inspection by Date PitJ r b out S- ti Additional Comments: ❑ Stk ;48"781' ` odi t'369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 •J l\ ice. Applicant Return all copies to:Environmental Health'Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 Sr 31iill �}'"1�4$ �1NT DUE AMOUNt REMITTED CASH RECEIVED BY DATE i PERMIT`N0. +EH13-24{REV.ti [. EH 1426