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r � APPLICATION FOR PERMIT r SAN JOAQUIN LOCAL HEALTH DISTRICT S,�, 1601 E. HAZE�TON AVE., STOCKTON, CA Telephone {209) 466-6781 PERMIT EXPIRES 1'YEAR FROM DATE ISSUED (Complete in Triplicate) inall the work describe . This is Application is hatewmade ith t Jthe San Joa ioaquin n Counquin Local ty Ordinance Nto.549 for sewage or Healh District for apermit No. 1862 for weii/to construdpump and the Rules and'R gulations of he Sang cation Joaquin made in compliance Local Health District. Or City S Lot Size PM Job Address Owner's Name Address 4 S �. Phone /j)qy — 20 Contractor n,, ,Qn�J t` Address �30f1n —L1Cense No. �p802. Phon �2 NEW WELL ®. _r t «WELL REPLACEMENT ❑ DESTRUCTION ❑ r I TYPE OF WELLIPUMP: OTHER � r' r "tPUMP INSTAtLATION ❑ SYSTEM REPAIR ❑ S`,'' �� SEWER L1NES DISPOSAL FLQ.1yL-'�- PROP. .4W DISTANCE TO NEAREST: SEPTIC TANK'—. AGRICULTURE WELL -�.'�_ OTHER WELL a19 PITS/ FOUNDATION INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS pia. of Wel{ Casing Ll industrial F1 Open Bottom ❑ Manteca Dia. of Well Excavation Specifications ❑ Domestic/Private - ® Gravel Pack ❑ Tracy Type of Casing H Other ❑ Delta Depth of Grout Seal y Type of Grout � r i l`] Public v Apprax. Depth l I Eastern Surface Seal Instal{ed by i I Irrigation — State Work Done Repair Work Done ❑ Type of Pump H.P. Well Destruction D Well Diameter Sealing Material Stop 501 C Depth Filler Material Melow 501 c system TYPE OF SEPTIC WORK: NEW INSTALLATION LI REPAIR/ADDITION l i DESTRUCTION I i aNailabPelwi bin 200 feetit�ed it public sewer ' In tion will serve: Residence— Commercial— Other Number o i i units: Number of bedrooms Wa le depth Character of soil to th of 3 feet: Capacity No. Compartments SEPTIC TANK ❑ Type Method of Disposal PKG. TREATMENT PLT. ❑ T Property Line Distance to nearest: F ton Total length/size LEACHING LINE ❑ No. 8 Length of line ert Line FILTER BED C1 Distance arest: Well Foundation V t SEEPAGE PITS I I Depth Size Number pro Line SUMP L] Distance to nearest: Well Foundation O ;AL PONDS ❑ V I 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, t shall not to become subject to workman's compensation laws of California." Contractor's hiring r to wcor s tFactig signature employanyany person in such manner as ompensa- certifies the following: "I certify that in the performan I' ce of the work for which this permit is issued, I shall employ p subject 4 tion laws of California." The applicant must call for all re wired inspections. Complete drawing on reverse side. — P Title: �lt41'EGf Crff�L�/Er-� — Date: Signed �}PPL.Ie'o 66oY * E�-! �#5{I Jr.I FOR DEPARTMENT USE ONLY �e��t`r] C�ctils Date + Area F Application Accepted by f Date Final Inspection by Date Pit or Grout inspection by / f Additional Comments: ❑ Stk 466-6781 ❑ L di 369-3 1 ❑ Manteca 823-7104 ❑ Tr`cy 835-6385 k Applicant - Return all copies to. Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 t a CK RECEIVED BY DATE PERMIT'NO. FEE A!!! AMOUNT REMITTED CASH INFO I 1 + EH1324(REV.tin5) --0 C) I I I ^ EH 1428 1