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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) I Application is Health District for a made n compfance wereby SanoJoaquan County Ord(na)nce No.549 for sewage . This application is permit No. 1862 for and/or ade n Joaquin well pump and the Rul s and IR Regulations of he San, or Joaquin Local Health District. Job Address 2 30 31*9 6 4(A1 aTT dad• City t-00 I?V-FOY4 Lot Size RNr.�idYTB PM Phone-340-0102 I Owner's Name 074-If AIV+rNC �� V"t-f VAddress S ; krf -9py Address SQA l ve VM A41(0- License No. yY —Phone Contractor 'Z3 r r71 4 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION LJ Y PUMP INSTALLATION ❑ SYSTEM REPAIR EJ OTHER ❑ # DISPOSAL FLD. PROP. LINE DISTP.NCE TO NEAREST: SEPTIC TANK SEWER LINES FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS IN USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Dia- of Well Excavation D.ia. of Well Casing Industrial ❑ Open Bottom ❑ Manteca I ❑ Domestic I Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 1 FI Cl Delta Depth of Grout Seal �' Type of Grout I'l Public f I I Itrigation —..Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work-Done_ Well Destruction ❑ Well Diameter Sealing Material Itop 50'1 Depth Filler Material (Below 501 l TYPE OF SEPTIC WORK: NEW INSTALLATIOI\14Vw REPAIR/ADDITION I I DE=STRUCTION 1 .)'+(No septic system permitted if public sewer is available within 200 feet.I installation will serve: Residence Commmercial)_ Other Number of living units: 'Number of bedrooms 8/Character of soil to a depth of 3.feet: Ado6G` Water table depth SO ,{ I /7xo C.I87 Capacity�« No. Compartments A SEPTIC TANK -m Type/Mfg PKG. TREATMENT PLT. ❑ ±Method of Disposal Distance to nearest: Well Xs0f Foundation 90 Property Line LEACHING LINE 0 No. & Length of Eines f Total length/size FILTER BED O Distance to nearest: Well Xp0 Foundation yam' Property Line 0"• ,. ,j Size De th f i 39" WA, Number SEEPAGE PITS j/I p, T.'� � � SUMPS L1 Distance to nearest: Well R 0'0 Foundation Property Line q0 DISPOSAL PONDS ❑ f I hereby certify that I have prepared fFiis application and that the work will be done in accordance with San Joaquin county ordinances, state laws and"t rules and regulations of the San Joaquin Local iHealth DiMrict. 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, E shall note t I employ any person in such manner as to ibero-r me subject to workman's compensation laws of California-" Contractor's hiring or sub-contracting signatu(e r certifies the following:"I certify that in fhe performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- E tion laws of California." t •!-- - f3 "` ` � `� The applicant must all for all required.in'w spections. Complete drawing on reverse side. bEt. 9 - -. -� tle: Date: f Signed X Ti _. ' FOR P PARTMENT,USE ONLY i; Area Application Accepted by � Date n ted incl Inspection by ate/JAL= J Pi or Grout Inspection by Additional Comments: ❑ Stk 466-6761 ❑ Lodi 369-3621 L1.Manteca f823-7104 O,Tracy 835-6385 J Applicant- Return all copies to: Environmental_Health-Permit/Services 1601 EC-Haz6lton Ave., P.O. Box 2009, Stk., CA 95201 i _ 1! FEE AMOUNT DUE AMOUNT REMITTED CIC RECEIVED BY DATE PERMIT'NO. INFO 1 _ �sl_ r.EH 13-24(REV. /n sl 1 -/0-•-- b �.{'