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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT N0. Telephone (209) 466-6781 DATE ISSUED PERMIT EXPIRES I YEAR�FROM DATE.ISSUED (Complete it Triplicate) y l the rein an Application is s applicationoishmadeninoaquin compliancelwiithlth SanOistrict for a Joaquin Countypermit to0 Ordinance No. 549tfordsewagesorlNo. 1862rforewell/pump described. This app �r and the Rules and Regulations of the San Joaquin L cal Health District, P U �a x a S �6 Job Address 3/1 CC e Subdivision Name f Phone Owner's Name .1 Address Contractor's Name ,v A License No. Phone TYPE OF WELL/PUMP WORK: NE41jWELL �] WELL REPLACEMENT ❑ DESTRUCTION ❑ i ` PUMP 1NSTALLATION� SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK .. ._ SEWER LINES DISPOSAL FLO. PROP, LINE }. ELL OTHER WELL PITS/SUMPS AGRICULTURE W FOUNDATION I i INTENDED USE TYPE OF WELL PROBLEM AREA r.✓ z CONSTRUCTION SPECIFICATIONS r 9 j ` ' Dia. of Well Excavation t' Industrial U Open Bottom [] Manteca �T 4 — -. " I Dia. of 41e11 Casing [,V f U Domestic/Private ❑ Gravet ct� ❑Tracy` K a ❑ Public [1 Other ❑ Delta Type of Casing J Ci Irrigation Approx"""— Eastern ❑ Specifications ycathodic Protection Depth Depth of Grout Seal ❑Geophysical Type of Grout Other Surface Seal Installed by �J e of Pump H.P. /Ss�3dxe:•WorkWDone_:---- e ----- r Repair Work Don TYP [ �i , Well Destruction 1-1A, Diameter Sealing Material (top 50') 1 r 1 Depth Filler Material (Below 50') sewe TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION t U (No septic tank or seepage Rp�availableewithind if u200cfeet.) is Installation will serve: Residence �� Commercial _ kOther - „Number of living units: Number of bedrooms Lat size s ; Water table depth Character of soil to.a depth of 3 feet; Capacity No. Compartments tSEPTIC TANK ❑ Type/Mfg Method of Disposal e Y PKG. TREATMENT PLT. []'.IT Mf, yP / 9 Capacity Propert Line SEWAGE SYSTEM I--� 'Distance to `nearest: 1Wel1 1Foundation Y 7f DESTRUCTION i Lam'- /.:". n i I LEACHING LINE U %No. '& Length,of linest Total length/size f R Distance t4_nearest: Well } Foundation Property Line ' .FILTER BED � . Depth _ Size Number >SEEPAGE PITS property Line . " '"� _Foundation —- *" 'SUMPS` Di stance to nearest:. Wel 1- 'DISPOSAL PONDS /--❑ r I' ication and that the work will be done in accordance with San Joaquin county hereby certify that I have prepared this applformance of ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. Home owner or lticensed agent's signature cerson�in suchFinannernas to become subjec that e tohwonkmaer n� compensatiionwlawsfof California." permit is issued, I shall not employ any p `. Contractor's Kiri�, Od, r sub contracting signature certifies the following: "I certify that in the performance of the work for whit this permit is I shall empl persons subject to workman's compensation laws ofCalifornia," The appy mallfqr re S. Comple awing on reverse side, Title:/ I.+/�P�'.S�xr�C�i�d52, Date: !a _,_EOR DEPARRT_TM�ENJ NSE 0 LY Ari k 466-67.81-.. } ",t"""'""'Appl'ication Accepted"by �Z_ZLodi 369-3621 I Additional Comments: Manteca 823-7104 � � :�, Date , �\ k _ Pit or Grout Inspection by 1 Tracy 835-6385 at Date L Final Inspection by P.O. Box 2009, Stk., CA 95201 e Applicant - Return all copies to: Environ e al Health Permit/Services 1601 E. Hazelton is RECEIVED BY DATE PERMIT NO. FEE BASE AMOUNT DUE AMOUNT REMITTED i, IN �q/ ti — �-t 10182 500 G EH 13-24 REV. 10/82 [vim 14-26