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I APPLICATION FOR PERMIT i SAN JOAQUIN LOCAL HEALTH DISTRICT PAYMENT i 1601 E. HAZELTON AVE., STOCKTON, CA RECEIVE® Telephone (209) 466-6781 MAR 2 1 1990 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED SAN JOAQUIN4 ;_'� NTY .Ceby a ©�_ �� _� {Complete in Triplicate) PUBLIC 1'EAL7 b� �,`,'QApplicaflofl is made to the San Joaquin Local Health District for a permit to construct and/or instalh4R� v dddIRegulation�r1T� ({% tion is made in compliance with San oaquin ounty Ordinance No.549 fogs wage or No. 1862 for welllpump and the Rules and Regulations of thean�oaquin Local Health District- , Job Address �`� City �"��'`d�� Lot Size 169 4C!Y=� PM * I Owner's Name � l l�f�� Address r` - - � "" ) Phone�J�.� 7- Contractors'ba tl Address Q 41 License No Phone ^ f TYPE OF WELL/PUMP: NEW WELLK WELL REPLACEMENT 11 DESTRUCTION 13 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER El DISTANCE TO NEAREST: SEPTIC TANK 1aLe'`' SEWER LINES_A DISPOSAL FLD. PROP- LINE FOUNDATION AGRICULTURE WELL --- OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 42 Dia. of Well Casing X-Domestic/Private Gravel Pack ❑ Tracy Type of Casing QSpecifications f"1 Public -'1 Other Cl Delta Depth of Grout Seal 7 Type of Grout- _. I I Irrigation 7Approx. Depth E I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.R. State Work Done Well Destruction ❑ Well Diameter' - !! Sealing Material ftop 501 r Depth If Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION i I DESTRUCTION I 1 (No septic system permitted if public sewer is available within 200 feet.) i Installation will serve: Residence_ Commercial F Other 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. d Method of Disposal Distance to nearest: Well Foundation Property Line I LEACHING LINE -❑ No. & Length of lines Total length/size I FILTER BED ❑ Distance to nearest: Well Foundation Property Line � SEEPAGE PITS Li.. Depth Size Number - `4lglJ{VIPS 0 Distance to nearest:: Well j Foundation Property Line DISPOSAL PONDS ❑ E I hereby certify that.) 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: "I certify that in the performance of the work for which this permit is issued, I shall not employ 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: "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 must call for all required inspections. Complete drawing on reverse side. Signed X -t Title: �11!l Q1n Date: OR EPARTNIENT USE ONLY a{ Application Accepted by Date Area Pit o Grou Inspection b Date i0 Final Inspection by ` Dated Additional Comments /4 ❑ Stk 466-6781 — ❑ L i 369.3621 ❑ Man ca 823-7104 ❑ Tracy 635 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazalton Ave., P.O. Box 2009, Stk., CA 95201 i FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO I . EH 13-241REV,i/y5) �] 5 _ 3 q 0 (] . Eli 14-2e