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I' l - j APPLICATION FOR PERMIT SAN JOAQUINLOCAL HEALTH DISTRICT r it i !l 1601 E. HAZELTON STOCKTON, CA AVE. R Telephone (209)"466-678, PERMIT EXPIRES 1YEAR F I ROM DATE ISSUED II Application is hereby made to the San Joaquin Local Heahh (District ae in Triplicate) made' compliance with San Joaquin County Ordinance No. 549 for sewage Local Health District. ` permit to construct and/or install the II f1e ar No. 1862 for well/ u work herein described- This a II P mp and the Rules and Re PPGcation is .Job Address I 1 Regulations of the San Joaquin u4i City S �T.v1 Lot Size S�`x1 .Owner's Name MM[ � PM c �O / Address Lon v>,to Contractor (,V� II. ' Phone 7 tis s,0,7 3z o s TYPE OF WELL/PUMP: � Address l�rrs�,r NEW WELL O - 9 License No, ,�� WEl-L REPLACE ENT ❑ Phone 47 1 PUMP INSTALLATIOfJ'� DESTRUCTION ❑ .. DISTANCE 70 NEAREST:,SEPTIC.TANK. SYSTEM REPAIR ❑ — ' d!. ' �'�� SEWER.LINES ____ f OTHER ❑ FOUNDATION AGRICULTURE WELD~-D1SP.OSAL-FLD. PROP, LINE INTENDED USE TYPE III WELL OTHER WELL PITS/SUMPS ❑ Industrial i1 PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Open Bottom a ❑-Man~� teca ❑ Domestic/Private Dia: of Well Excavation 0 Gravel Pack ¢ Dia. of Well Casing ❑ Trac ('1 Public ill' y Type of Casing rl Other E Delta Specifications I ).irrigation - % 4II Depth of Grout Seal —..Approxi Depth .kI-1 Eastern Surface Seal Installed by Type of Grout Repair Work Done ❑ Type of�Pump H.P. State Work Done Well Destruction ❑ Well Diameter IIII Sealing Material (tap 50') Depth 4 Filler Material {Below 501) J TYPE OF SEPTIC WORK: NEW INSTALLATION i 1 RE AIR !_I DESTHUCTION { I (No septic system permitted if public sewer is J Installation will serve: Residence available within 200 feet.) f Commercial Other f Number of living units: �! Number of bedrooms Character of soil to a depth of 3 feet: 1.4 SEPTIC TANK Water table depth ❑ Type/•iMfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ I , Method of Disposal Distance to nearest: Wel! Foundation Property Line LEACHING LINE ❑ No. &ILength of lines Total length/size FILTER BED 1-1Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth''f Size Number SUMPS Ll Distan'llce to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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 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." Contractors hiring or sub-contracting signature certifies the following: "I certify that ii' the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." I I The applicant all f 11 requiredIIinspections. Complete drawing on reverse side.. Signed X Title: 421WMA Date: -19 u FOR DEPARTMENT USE ONLY Application Accepted by r� Date -;�z-$'I 1 rl ' Area Pit or Grout Inspection by Dat I� Final Inspection by Date Additional Comments: O Stk 466-6781 ❑ Lodi 369621 © Manteca 823-7104 © Tracy 835-6365 Applicant - Return all copies to: Envi101 nmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 1, INFO FEE AMOUNT DUfE AMOUNT REMITTED GASH RECEIVED BY DATE PERMIT'NO. ♦.EH 1324 1R EV.t/95) I.I [''.. I i