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` I N 1-',ty}� '. - ., - a r7:^.:F, rl'.-..•-. a.-„n q.y.,,,r r APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E, HAZELTON AVE., STOCKTON, CA Telephone (209) 466.6781 I PERMIT EXPIRES 1 YEAR FROM DATE !SSUED (Complete 'tit Triplicate) d AppliGatlon is hereby mode to the Sen Joaquin Local Health District for a permit to construct endler instal!the work hereln'defcnbed.TNI appfkat{on 1a _ made in enmpliancG with Sa.i Joaquin Cnunry Ordinance No.549 for sewage or No. 1B62 far well 1pu:np end the Rules and RegulatbM o1 the San Joaquin -� -' Local H;allh District. �38�3 f"st/�L 01Y 131,LerA � City ArCa9't.1✓ Lot Site PM 7 { Job Address Qwnar's Name c"_?1�p�7 .s� Address �_+ - PhaM gL Contractor !!r�•r/ Sa/V Address0iv& o0pi License t3o. �`8 r_`'Phone�u��'%�^ fj TYP@'OF„WELLlPUMP; NEW WELL ❑ WELL REPLACEMENT LJ DESTRUCTION 0'.. PUMP INSTALLATION ❑ SYSTEM REPAIR Q 'OTHER Ca sin r r DISTANCE TO NEAR[ST: SEPTIC TANK SEWER LINES DISPOSAL,FID.� _ PROP LINE , t j FOUNDAT10N AGRICULTURE WELL OTHER WELL P1T$ISUMPS �, INTENDED USE - TYPE OF WELL PROBLEM AREA. CONSTRUCTION SPECIIFICATiDNS L3 Industrial 1'1 Cpen Bottom Fl Manteca Dia.of Well Excavation Dia Well Casing ❑Domestic:Private L-1 Gravel Pack I']Tracy Type of Casing SpeClfeB Iona {'!Public 17 Other ri Daha Depth of Grout Seal i Type o}^itout�, I t Ifrifjation __.Approx. Depth I I Eastern Surtaca Seal Installed by r ' Lr �I Repair Work Done I.7 Type o1 Pump.,..._ H.P. St I ate Work Done,� 11 Well Destruction LlWell Diameter. Sealing Material(top 50') Depth Filler Material(Below 601 '' ' TYPE OF SEPTIC WORK; NEW INSTALLATION I I REPAIRIADD!TION)Q DESTRUCTION I I INo septic system permitted if public sewer Is available within 200 tent.) f rT Installation will serve: Residence-t—: Commercial_ Other „c Number of living units:-J___._ Nu,nber of bedrooms Character o1 sail to s depth of 3 feet: Rcfniti —_— Water table depthy. SEPTIC TANK I-] Type/Mfg Capacity-,— No.Wnpartrnerits { PKG.TREATMENT PLT.Cl Method of Disposal 1 Distance to nearest: Well Foundation _ PropenV Line z, LEACHING LINE n No.6 Length of lines Total length/size- --FILTER HED U; D;stance tc.nearest: Well Foundation Property Line SEEPAGE PITS 1 I Depth -1 r' Size -5'� f $� _ Number 7.' -7 `� { SUMPS 10; Distance to Nearest: Well Fourldocwn Property Line }° v DISPOSAL PONDS 17 :.- ! I hereby certify that I have prepared this application and that the work w3l be done in accordance with San Joaquin r:,wnty ordinances,slats laws and °, ,u$es and regulations of the San Jneyuin Local Health 011.16ct. Home cwner or licensed agent's signature certifies the following:”]certify that in the parformanca of the work for which tl;is permit Is iuued I shall trot employ any person in such manner as to become subject to workman's co laws of California."Contractors hir4tg qr wtrcon[racting ltlgnature car!ilias the following:"I certify that in the perform'gAca of the work for which thiv permit is issued,I shall employ persons tubject to workman'scompenes tion laws o1 California." The applicant m st call for all required inspec' ins. Complete drawing on reverse side. - R F Signed X Title: Date: r F00,16 E P A Application Accepted by 4 .r _ Dere Aes i Pit or G-^„t Inspection by -ate Final Inspection by ' Dere - Additional Comments: Li Cl Stk 466-6781 P Lodi 369-3621 ❑Manteca 423.7104 ❑Tracy 835.6385 Applicant-Return all copies lo; Environmental Health Permit/Services 1601 E. Hwiton Ave., P.O. Box 2009,Slk., CA 96M 4 rFEE AMOCINY DLIf AMOi1NT REMITTED CAS1+ REC{IVFO BY DATE PFRMIT'NO - tNfO .{HIS-)4i4ttr.rrxaf EM 11)a h' i? i