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APPLICATION FOR PERMIT �� SAN JOAQUIN LOCAL HEALTH DISTRICT R�G "IV G 1601 E. HAZEL T ON AVE., STOCKTON, CA �� • Telephone (209) 466-6781 P `c A PERMIT EXPIRES TYEAR FROM DATE ISSUED --- fete in Triplicate) �Mr1CA�1� 5 • (Comp p nA1T#5�R • wa a or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin made{ Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herA0eNscrlbed. This application is made in compliance with San Joaquin County Ordinance No, 549 or 9 Local Health District. ., p ` Q G F LA LOAI Lot Size PM City, ` Job Address It UeJV 12,4 Phone [Je�v �'f Rg_ Address C41 ly, Owner's Name —TCA. ZOO Q ` Phone fY� d Address D© al License`!f�o. 7 Contractor .r�� ov DESTRUCTION ❑ r �. ' ' ' a NEW`WELL 1 A 1 WELL:REPLPCEIIAENT ❑ �TYP.E'6F; WELL 1PUMP:� SYSTEM,REPAIR ❑ OTHER ❑ 1 PUMP INSTALLATION ❑ 1- ) t) `%DISPOSAL FLD. PROP. LINE ! SEWER LINES DISTANCE TO NEAREST: SEPTIC TAN :AGRICULTURE WELL OTHER WELL""- "" 'ITSISUMPS �` FOUNDATION----- t INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing Dia. of Well Excavation ❑ Industrial ❑ Open Bottom ❑ Manteca Specifications Type of Casing Typ XDomesticlPrivate ❑ Gravel Pack ❑ Tracy Type a1 Grout f 1 Cl Other ❑ Delta Depth of Grout Seal n [I Public i ."--- " 1 �.-Approx. Dept l I Eastern Surface Se' Installed by: R I I Irrigation I H P l 9 {State tiNo k Done Repair Work Done Q Type of Pump f r Sealing Material (top 50') � V� Well Destruction ❑ Well Diameter 1 - Depth - r Filler Material IBelow 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIRlADDITIDN l I DESTRUCTION l } alvailablelwi within 200 1eetl jed if pudic sewer is r. Installation will serve: Residence Commercial— Other # Number of livingNumber of bedroom units: s. , Water table depth it Character of soil to a depth of 3 feet: , Capaaty '" No. Compartments M SEPTIC TANK � �❑ TYpe/Mf9 Method of Disposal PKG, TREATMENT PLT. ❑ '` } -�'•• Property-Line Distance to nearest: Well^ Foundation # Total length/size— LEACHING ength/size LEACHING LINE ❑ No. & Length of lines F FILTER BED ❑ Distance to nearest: Well Foundation Property Line Size _ Number SEEPAGE PITS 11 Depth --- i Foundation Property Line - Ll Distance to nearest: Well - SUMPS � �,,..�,,,.�"""�� ,- .��.�� „��Thi�.. � DISPOSAL PONDS 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances state Paws, and rules and regulations of the San Joaquin Local Health District. Home owner or licensed agent's signature certifies the following: "i certify that in the performance of the work for which this permit issued, I she not ' laws of California." Contractors hiring or sub-contracting signature employ any person in such manner as to become subject to workman's compensation is issued, I shall employ persons subject to workman' certifies the following: '9 certify that in the performaI oof the work for which this permit s compensa- tion laws of`California-"`•""-'""' tl 3 The applicant m all for all req ens tions. Complete drawing on reverse side. , f— TitFe Date: s Signed X f F RRTMENT USE ONLY F Date D rea Application Accepted by .�. Date Pit or Grout Inspection by Date Final Inspection by Additional Comments: `? lf- i ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823 7104 l r❑ Tracy 635=6385 �.' \ " s Applicant - Return a6 copies to: Environmental Health Permit/Services 160] Ea.Haielt'on Aire:'P.O. Box 2009,Stk�EA 95201 FEE AMOUNT DUE AMOUNT,REMITTED H RECEIVED BY DATE PERMITNO INFO 13 g' +.EH 13-24(REV.1/145) 3� / O 7s EH 14-26