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APPLICATION FOR PERMIT SAN JOAOUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA k Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This application is Application is hereby - or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin made in compliance with San Joaquin County Ordinance No.549 for sewage Local Health District. 1 13i� ��, PM }` City AOR/_ Lot Size d Job Address Phone Owner's Name ,Qui �� Address O�S7 (` 1 O MoilOOrV License No. `� `" '4�Phone pR/ ow Address •�•�pX 1 Contractor WELL REPLACEMENT ❑ DESTRUCTION ❑ TYPE OF WELL/PUMP: NEW WELL ❑ OTHER ❑ SYSTEM REPAIR ❑ PUMP INSTALLATION ❑ a DISPOSAL FLD. PROP. LINE SEWER LINES �� PITS/SUMPS DiSANCE 70 NEAREST: SEPTIC TANK AGRICULTURE WELL OTHER WELL j FOUNDAT.ION..-y—�- INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia of Well Casing ❑ Open Bottom , ❑ Manteca Dia. of Well Excavation l ❑ Industrial c s" Type of Casing Specifications ❑ Gravel Pack ❑.Tracy Type of Grout ❑ Domestic/Private E3 Delta Depth of Grout Seal C] Public ❑ Other _--Approx. Depth ❑ Eastern Surface Se V Installed by El Irrigation '' �'� State Work Done H.P. Repair Work Done 1-1Typeof Pump Sealing Material {top,50'} # Well Destruction FJ Well Diameter �� 50'} , Depth Filler Material (Below N ❑ REPAlR/ADDITION pe DESTRUCTION ❑ (No septic system permi TYPE OF SEPTIC WORK: NEW INSTALLATIOtted if public sewer is # available within 200 feet.) r —�— Installation will serve: Residence Commercial Other Q Number of living units: Number of bed ooiris i 0 _ .�# Water table depth Character of soil to a depth of 3 feet: ,4 .3kia„, Capacity�� No. Compartments SEPTIC TANK ❑ Type/Mfg e I Method of Disposal PKG. TREATMENT PLT. ❑ - 'F dation Property Line -- Distance tot nearest: Well F --, , , _ /Ov Total length/size LEACHING LINE �f No. &,Lengfh of lines �;�� Property Line!1-” f --,. �',� Foundation� �- v i r FILTER BED ❑ Distance to nearest: Well 'i } t Number/ *'F:: , �+=f ❑ Depth °s . Size SEEPAGE PITS � . Foundation Property Line.�� i ❑ Distance to nearest: rl Well ti P r - t SUMPS 1 [ S ❑ 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, an DISPOSAL PONDt rules and regulations of the San Joaquin Local Health District. g compensation laws of California." Cantractofs hiring or subcontracting signature Home owner or licensed agent's signature certifies the District. it. 1 certify that in the performance of the work for which this permit is issued, l a no employ any person in such manner as to become mancect to workman's of he wok far which this permit is issued,l shall employ persons subject to workman's compensa- certifies the following: "I certify'that in the pe , tion laws of California." quiInspections.� Complete/drawing on reverse side. The applicant must call for all re Date: Title: Signed FOR DEPARTMENT USE ONLY i Date Area P Application Accepted by r �)� � �� Date��— Pit or Grout Inspection by Date�� Final Inspection by f Additional Comments: p Manteca 823 7104 ❑Tracy 835 8385 A 95M1 El Stk :466-6781 ❑ Lodi 369 3621 Applicant- Return all copies to: Environmental Health th Permit/Servic..es 1�1 E'Hazekon Ave., P__O..Box 2009, 5tk.,- .- r-- CK RECEIVED BY i DATE PERMIT'NO. FEE AMOUNT DUE AMOUNT REMITTED CASH ` INFO + EN 1324(REV.1/a5) EH 14-26