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h f APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1-315.2 b 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 i PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) OF install the work herein describe , Th s PP Application ha nee mhith SanoJoaquinthe nJoaquin County ordinance HeaLocal No. 549 for sewage or cation is Ith District for a permit No. 1862 forcwell pump and the Rules and Regulations of the San'Joaquin I made in p Local Health District. I � City �^ Lot Size_L: PM Job Address OS M �� >� Phone Address Owner's Name. f ' f�r� --• -=—Address T• � `�'-•- - •-•-� - �--License No:-��rst�� Phone +� Contrattor DESTRUCTION ❑ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 11 s PUMP INSTALLATION Q SYSTEM REPAIR ❑ OTHER 13 i DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. POOP. LINE f FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS I -,71 0BL"EM' AEA CONSTRUCTION SPECIFICATIONS INTENDED USE TYPE rjNELL` + Dia. of Well Casing ( ❑ industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation f Type of Casing Specifications ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy yp Type of Grout f`l PublicfA f 1 Other 1 1 Delta Depth of Grout Seal I ! Irrigation 'f • fApprox. Depth t I Eastern Surface Seal Installed by i H p State Work Done_ Repafir Work Done t ❑ N TyipeN Pump ak WL-11 Destruction ',.) ❑',.W.,ell Diameter Sealing Material {tap 50'? 7'; F Depth-" Filler Material IBelow 501 TYPE OF SEPTIC WORK: NEIN'INSTALLATION 11 IREPAIRlADDITION�' DESTRUCTION l I (No septic system m rented if public sewer is .fi Installation will serve: Resider�e Other r+ i[. d Number of living,units: Numbers f bedrooms - Character of soil to a depth iof 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG.:TREATMENT PLT. ❑; Method of Disposal r-- ••- _��, -- �distance to nearest: Wel Foundation Property Line LEACHING LINE No & Length of Dines ,��------------------------- T,ot�al Ie�th/size l FILTER BED LJ Distance to is Wel Foundation__45t oparty Line A SEEPAGE PITS i'l- ,Depth �� '� Site Number SUMPS L�",f;C]isiance to`i5earest:.,- Weli - Foundation` Property Line % y DISPOSAL PONDS ❑,.�' ' I hereby certify that i have prepared this applicationhand-that the�work will be done_ in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the Sai57)o'griin Local fiealtf District. �,r- Home owner or licensed agent`'srsignature certifies the following; "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner-as4to 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 woFll for which this permit is issued,I shall employ persons subject to workman's compensa- tion laws of California." r The applicant must call for al equi d.inspections.-Complete-drawing-on•reverse side. � � `Z' k' Title: Date: k Signed ! iFO ARTMENT USE,ONLY ; ;•• —•:` Date Application Area Application Accepted by _ r Pit or Grout Inspection by Date Final Inspection by Date F Additional Comments: ❑ Stk 466-6781 El 369-3621 C1 Manteca 823-7104 ❑ Tracy 835 6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E Hazelton Ave., P.O. Box 2009, Stk., CA 95201 r CK RECEIVED BY "DATE PERMIT-NO. FEEL a;AMOUNT DUE AMOUNT REMITTED CASH' r .INFO w�, i,�r�Y?'rH�t�}�4 lRE4,-ti%rst51 �%l� lar - �.•