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APPLICATION FOR PERMIT 61 Ot) SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA I Telephone (209) 466-6781 PERMIT EXPIRES 1-YEAR FROM DATE ISSUED l (Complete in Triplicate) 0-71 ^ X70 r alth District for a permit to construct and/or install the work herein described. This application is Application is hereby made to the San Joaquin Local We No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin made in compliance with San Joaquin County Ordinance Local Health District. 1.17 f J^. 4ki1 i& _( y ,! �1 i Job Address 5E Corm fT�mrcw fit' a4arfRer �� City �F"� � Lot Size� OX �[oC1 PM gloo suslnt5r t�+-u- Dr.�2� 1� q1 JJ/,, g$2 366 '577 Owner s Name 1 �c�r � Address spa'�h� q 7 Phone VV Sacrar>~ar� CA as 6 q( 9�b pp 9 � -� j +-r..rsf.rrr.r +• 1{� �1' •y"""�"""L.icense No. Phone 71 I b O vv ' Contractor rC �In Address TYPE OF WELL/PUMP: NEW4VHL X8011VAJ S WELL REPLACEMENT ❑ DESTRUCTIONS PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ O DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE t FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF.WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial COM-16 etat ❑ Open Bottom ❑ Manteca Dia. of Well Excav_a_tr��n - Dia. of Wel{ Casing r g /Ydn�� Specifications CD Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casin P [`l Public (Other .3 Cl Delta Depth of Grout Seal +[ti I_,��h - Type of Grout �n l I Irrigation ?r�-Approx, Depth I I Eastern Surface Seal Installed by ` Repair Work Done ❑ Type of Pump H.P. State Work Done ° f/ �r b Well Destruction Llt Well Diameter ' __. Sealing Material (top 50'1vr" ,�ndi-4tr� �n+ 5 Depth 2SIF� Filler Materia! (Below 50'1 TYPE OF SEPTIC,WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION ! I DESTRUCTION I I't(No septic system permitted if public sewer is e ,- ravailable within 200 feet.) Installation will serve:' Residence" Commercial_ Other i IL Number of living units: Number of bedrooms ■ '' Water table depth Character of soil to a depth of 3 feet: �SEPTIC;,TANK ❑ Type/Mfg Capacity No. Compartments t� Method of Disposal i -,,PKG. TREATMENT PLT. ❑ r Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines 4fTotal length/size FILTERBED ❑ Distance to nearest: Well Foundation / Property Line SEEPAGE PITS I 1 Depth Size Number SUMPS Ll Distance to nearest:.. Well Foundation Property Line DISPOSAL PONDS El I hereby certify that I have prepared ihis application and that the woik will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. Home owner or`licensed agent's signature certifies the following:�'l certify that in the performance of the work for which this permit is issued, I shalt not employ any person in such manner as to 5et:ome subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following: "I certify.that in the Xrformance of the work for which this permit is issued,I shall employ persons subject to workman's compensa tion laws of California." Jj The applicant st_ call for all required inspections. Complfefa drawing on reverse side. Signed + Title: &iGrrieQd�?, Date: 8 FOR DEPARTMENT USE ONLY Application Accepted by Date rea Pit or Grout Inspection by I to Final Inspection by Date I Additional Comments: t ❑ Stk 466-6781 ❑ L -3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to:.Env ironmental Health Permit/Services 1601 E. Hazelton Ave., PA Box 2009, tk., GA 95201 i. t FEE OUNT DUE AMOUNT REMITTED CK RECEIVED BY EDATE PERMIT NO. t INFO+ EH 13-244REv.ii H 5r p a�sf EH 1426