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ti APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA i Telephone (209) 466-6781 ; PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ; (Complete in Triplicate) /or install the work cation is made in Application om compliance with Sanereby made toJoaquin County Ordinance No.649 for sewage or the San Joaquin Local Health istrict for a permit No 1862 for cwellldpump and the Rules and IR gulations of he San l Joaquin P Local Health District. �IZ7Y_Job Address !. �UL"!> 37 City Lot Size/ �jyj PM ; Owner's Name � t'i F' Addressf� � � Phone - 6_., cf' 4 LIL Phone o Contractor's Name z' License No. ;TYPE OF WELL/PUMP: NEW WELL �' WELL REPLACEMENT 1:1 OTHER ❑ i PUMP INSTALLATION�� SYSTEM REPAIR ❑ OTHER El r DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES tlDISPOSAL FLD �— ._. PROP. LINE -------FOUNDATION,—',' _h � , AGRICU00RE WELL OTHER WELL_ " PITS�7SUMPS LS4 INTENDEDUSETYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Ti Dia. of Well Casin❑ Industrial ❑ Open Bottom Manteca Dia. of Well Excavation—� � b Domestic/Private Gravel Pack ❑ Tracy Type of Casing PVC- Specifications ! 'r± Type of Grout ';"C r ❑ Public Other ❑ Delta Depth of Grout Seal ❑ Irrigation1,193 -Approx. Dept�lEastern -Surface Seal Installed by ✓ Repair Work Done Fl- Type of Pump H.P. I_. State Work Done 1y7 Sealing Material {to ,50') Well Destruction ❑ Well Diameter 9 P � Depth Filler Material 03elow 501 TYPE OF SEPTIC WORK: NEW.INSTALLATION ❑ ..REPAIR/ADDITION ❑ DESTRUCTION ❑ INo septic system permitted if public sewer is available within 200 feet.) T► Installation will serve: ; Residence_ Commercial+ Other Number of living units: Number of bedrooms r/� .Character of soilito a depth lof 3 feet: Water table depth V SEPTIC TANK f ❑ Type/Mfg Capacity - No. Compartments ,i Method of Dispdsal PKG.. TREATMENT PLT. ❑ - - �•- _-.� -- " Distance to nearest: Well Foundation, Property Line 1 J � P "LEACHING LINEEl No.,& Length of lines Total length/size FILTER BED ❑ Distance to nearest: Weil, . Foundation Property Line / SEEPAGE-PITS ' ❑ Depth Size Number )SUMPS ❑ Distance to nearest: Well Foundation Property Line i DISPOSAL PONDS ❑ 1.1 Hereby certify that 1 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. ify that in the performance of the work for which this permit is issued, I sign not Home owner or licensed agent's signature certifies the following: "I cert employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's 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 st call for all requir d inT ctions. Complete drawing on reverse side. Signed �l")t�1 l r L� Title: Date: I9 FOR DEPARTMENT USE ONLY � -?-S— Application Accepted by i� Date �2 Area Pit or Grout inspection by Date Final Inspectiongel,-z— Additional Date Comments: 4 ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 [] Tracy 835-6385 `I Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 t f FFE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. �,5.— ]LI$ + EH 13.24(REV,10!83) �, / SS�1�17