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x- APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 160.1 E. HAZE T ON AVE., STOCKTON, CA r Telephone (208) 466-6781 I PERMIT EXPIRES TYEAR FROM DATE ISSUED ` (Complete in Triplicate) T 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 made•in-compirance_with San Jpaquiq County,Ordmance:No 5494or.sewage or No: 1862 for well/pump and the Rules and Regulations of the San Joaquin Lo aI HebItf•,l DlstnCt-.'(ry J : Ns{r'l.y.K<§,�,; Job"Address $$� 1 ' )lo� 1IoY X11 IIYk Lt�.t,. 4 City Tracy Lot Size PM li Owner's Name George. Whitlock Address 1131 Marian Ct., Tracy Phone 835-6338 I Contractor HPnninnoz Bras._ Address 8525 DPlanrialp- Mod- License No._2q0813 -%-IPhone TYPE OF WELL/PUMP: NEW WELL EX WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK 100' SEWER LINES:- DISPOSAL FLD._1O0 t PROP. LINE ` f vFOUNDATION, AGRICULTURE-WELL• OTHER.WELL . P_iTS/SUMPS _ f INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Weil Excavation 1111 t1 Dia. of Well Casing 6n IX Domestic/Private OQ Gravel Pack Tracy Type of Casing PVC __ Specifications F1 Public ❑ Other P Delta Depth of Grout Seal 100, Type of Grout Ainton i to _. I I Irrigation _.,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 (top 501 Depth Filler Material (Below 50') �J TYPE OF SEPTIC WORK: NEW INSTALLATION (l REPAIR/ADDITION (.I DESTRUCTION i I (No septic system permitted it public sewer is i- available within 200 feet.) Installation will serve: Residence= Commercial 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. ❑ E Method of Disposal t Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line li SEEPAGE PITS i I Depth Size _ Number /,� y SUMPS Ll Distance to nearest: Well Foundation Property .r DISPOSAL_PONDS ❑ - I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaqur ty�fdinances, state laws, and rules and regulations of the San Joaquin Local Health District. V t Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which thisvrmit is issued, I shall not i employ any person in such manner as to become subject to workman's compensation laws of California." Contractors 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 inspectio Complete awing on reverse side. Signed i Date: FOR.RE ARTMEN USE OfVLY Application Accepted by Date r�--HCl Area q Pit or rou Inspection D,aatte� Final Inspection by Data Additional Comments: �ey1;4 ❑ Sik 466-6781 ❑ Lodi 369-3621 0-Manteca 823-7104 ❑ Tracy 835-6385 �_ t Applicant - Return all copies to: Environmental.Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 INFO FEE A OUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMI7'NO. � EH13.241REV-1/95r - k EH 14-26 CID �2