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' APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> ' Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1'YEAR FROM DATE ISSUED <br /> yl IComptete in Triplicate) <br /> ' or No. 1862 for welllpump and the Rules and Regulations of the San <br /> Won is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This app it <br /> n compliance with San Joaquin County Ordinance No:549 for sewage, <br /> 4ealth District. M <br /> j w ^ p <br /> .�` ,/ nY � J�A.�A ��l City /i C/9 M/'D _ Lot Size P _ <br /> ddress `i > �f- <br /> ��p Address � �S' �=H Phone � qL <br /> r°s Nam 9 <br /> �,(31�P/!PS'77NI1'9a.. _ _��—v�—• _ - 3b 2S, <br /> ' •pp - . gx 6 .`op�_,Ga..License No.'s ZZ � Phone G= <br /> actorE�y�s •S'Lt�/�% � AI]dress_ <br /> NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> OF WE_ LL_ lJ PUMP_ SYSTEM REPAIR ❑ OTHER ❑ <br /> ' PUMP INSTALLATION ❑ <br /> SEWER LINES DISPOSAL FLD. PROP. LINE <br /> ANCE TO NEAREST* SEPTIC TANKS PITS/SUMPS <br /> . FOUNDATION AGRICULTURE WELL OTHER WELL <br /> ' tlTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATK)fJS Ola of Well Casing <br /> dustriaC2C]l Open Bottom Manteca Dia. of Well Excavation Specifications <br /> - Type of Casing <br /> omesticlprivate ❑ Gravel Palk �❑ Tracy Depth of Grout Seal Type of Grout__- <br /> 71 Other I F1 Delta o <br /> ublic Surface Seal Installed by <br /> ' rigation^ —Approx. Depth I I Eastern State Work Done_ <br /> H.P. <br /> lir Work Done- ❑ Type of P0Sealing Material flop 50'1 <br /> Destruction ❑ Well Diameter <br /> Depth 1T Filler Material iBelow 501 <br /> ' eet.l <br /> E OF SEPTIC available within 200 f <br /> WORK: NEW INSi ALLATION REPAIRlADDITION L I DESTRUCTION I I (No septic system permitted if public sem <br /> t1t1 <br /> stalletion will serve: Residence p_r' Commercial— Other <br /> ' umber of living units: _— Number of bedrooms Water table depth <br /> haraeter Of soil to a depth of 3 feet: f ly'',A ��/ No. Companments — <br /> 'TIC TANK - ❑ Type/Mfg Capacity-4119-74 Method.of 0spgs@I- <br /> ' 3, TREATMENT PLT.O_ Foundation property L'^a <br /> Distance to nearest: Well <br /> ,r *Total Iength/sizer [moi <br /> iCHING LINE No. & Length of lines [ t Property Line <br /> ' ❑ Distance to nearest: Well Foundation . <br /> TER BED I ' <br /> Number <br /> EPAGE PITS I I Depthi,.7_�r"---Sr ?3 r r <br /> Foundation property Property Line <br /> ' IMPS ❑. Distance to nearest: Well <br /> SPOSAL PONDS ❑ r� <br /> Hereby certify,that I have prepared.this application and that the work vnTl tie don`in accordance with San Joaquin county ordinances, stat <br /> es and regulations a the San Joaquin Local Health following. _ <br /> ' 1ma owner o�loce n suc�ma nersignature <br /> as t*become subject t wlorkman'scompensation law3 of Caldomia.e Contractor'sslhiring or sub-cont�I,l <br /> (ploy any pa performance of the work for which this Permit is issued,1 shall employ Persons subject to workman's <br /> nines the following:"I certify that in the <br /> .n laws of C"al'�if�oor�rjjnia. CA" <br /> to applicanypyr�.call all require actions. Complete drawing on re�rsa side. { <br /> 1. <br /> % Title: •:•<iI Date: % /Y <br /> gned <br /> FOR DEPARTMENT USE ONLY / T Z/ Z <br /> • <br /> Date <br /> c Area <br /> ' pplication Accepted by - Date_ <br /> Dale Final Inspection by "'� <br /> it or Grout Inspectio <br /> additional Comments: ❑ Lod( 3633821 ❑ Meiitecs W-7104 t -I]Tracy 835-6385 <br /> } Stk X701 Stk., CA 952D1 <br /> ,pplican4 - Return all copies to: Environmentel Health'Pemrit/Services 1601 E'HazeltonAve., P.O. Box 2009, <br /> ' K RECEIVED By DATE PERMIT NO. <br /> FEE AMOUNT DUE AMOUNT R�EMITTED H.. <br /> INFO .(h]r/y <br /> .24 eREV.s/eel -*17 <br /> O <br /> 25 <br />