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f i s I APPLICATION.FOR PERMIT i� SAN JOAaUIN LOCAL HEALTH DISTRICT 3. 1601 E. HAZELTON AVE., STOCKTON, CA 1 Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED .,,. . I, _ (Complete in-Triplicate) to the San Joaquin Local Healterein described.This application is h District for a permit to construct and/or install the work hJoaquin Application is hereby made 1662 for well/pump and the Rules and Regulations of the San made in compliance with San Joaquin County Ordinance No.549 for sewage or No. Local Health District. 3 dNN�%rLo_LAM', City Lot Size S PM Job Address a Phone 1 'i Address Owner's Name �Q i ' , (1,. !lx ^/6 7 6? License No.3 z�Z7� Phone Contract Address DESTRUCTION ❑ t TYPE OF WELiL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ ! F STEM REPAIR Ll OTHER ElSY PUMP INSTALLATION 71 DISPOSAL FLD. PROP. LINE iC DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES !� FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS s INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing ' El Industrial �I ElOpen Bottom ❑ Manteca Dia. of Well Excavation specifications ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing ❑ Public ❑ other ❑ Delta Depth of Grout Seal Type of Grout 1 ---Approx. Depth ❑ Eastern Surface Seal-Installed by ❑ Irrigation I State Work Done Repair Work Done ❑ Type of Pump H.P. iSealing Material (top 501 Well Destruction ❑ Well Diameter Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system m feet.) if public sewer is ? / Installation Other will serve: Residence Commercial� t � h � Number of living units: Number f edroo a Water table depth Character of soil to a depth of 3 feet: c90-0 No. Compartments Capacity -.0 V% SEPTIC TANK Type/Mfg ` i _=-;Method•of-Dir6sal PKG. TREATMENT PLT.❑ oQ' prapemr'iLine -S Distanc�etngth elines �WellS Foundation ., t � .ate 7�� total length/sizer a ; ,! w LEACHING LINE L�'f No. & LProperty Line FILTER BED ❑ Distance to nearest: Well Foundation /d ! y II 1 " 1 Nun`iber SEEPAGE PITS Depth t S Size , Foundation—. 0 Property Line - i' SUMPS I`. ❑ Distance to nearest: Well Q i DISPOSALIPONDS ❑ 5 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, and rules and regulationt. s of the San Joaquin Local Health District."` ''W Home owner or licensed agents signature certifies the following: "I citify that in�the performance of the work forwhich this permit is issued, 1 shall not ter" rs- sub'ecttoworkman'scompensa- employ any person in such manner as to become subject tofworkman s.compensatiornilaws.of California." Contractor's-.hiring or sub-workman's signature certifies the following: "I certify that in the performance of thew"ark for which this permit is issued,I sh^ all Tt1�PIoY_Pe 1 tion laws of California.".... 1 The applicant call for al quir d inspections1C6_mp11t- drawinglon-reverse siidde.----�—t c�� Date: �`-' Q Signed t Title: X '� "" d FOR DEPARTMENT USE ONLY Date Area Application Accepted by 27 t j �✓ final Inspection by Date Pit or Grou Zy t Inspection by Date f Additional`Comments:r ❑ Tracy 835 6365 1 ElSt1c 466-6761 El Lodi 369-3621 Manteca 823-7104 th Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk Applicant'- Return all copies to: Environmental Heal ., CA 35201 i CK RECEIVED BY DATE PERMIT NO. PEE AMOUNT.DUE, AMOUNT REMITTED CASH !' INFO I I dC v� �... ..}+ EH 13-29 IAEV. EH 14-2d y'; rte. ' ..... ... .. ..