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i • APPLICATION FOR PERMIT SAN JOAO.UINLOCAL VE., STOCKTON RCAT 1601 E. HAZE 6781 . Telephone (209) 466- TE ISSUED PERMIT EXPIRES I YEAR FROM DA t; (Complete in Triplicate), application is permit to construct and/or install the work herein described._This e or No. con for well/pump and the Rules and Regulations of the San Joaquin Application is hereby made to the San Joaquin Local Health District for a pe y made in compliance with San Joaquin Cou 'ty Ordinance No. 549 for sewag Local Health District. r/ `f PM -- : City Lot Size �o� r �- Job Address , .. - - A� _ -- Phone Address L Owner's Name Phone "'f License No, �r� �,.--Address— — -- DESTRUCTION C Contractor WELL REPLACEMENT ❑ OTHER FJ NEW WELL ❑ TYPE OF WELLfPUMP: SYSTEM REPAIR ❑ PROP. LINE PUMP INSTALLATION ❑ DISPOSAL FLD.— PITS/SUMPS SEWER LINES —� OTHER WELL—� DISTANCE TO NESEPTIC TANK —�� AGRICULTURE WELL FOUNDATION —� ' PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia of Well Casing — TYPE Of WELL INTENDED USE —�~ Dia. of Welt Excavation -1 Specifications • ., ❑ Open Bottom ❑ Manteca — , ❑ Industrial ❑ Tracy Type of Casings Type of Grout _— C Domestic/Private ❑. Gravel Pack Depth of Grout Seal ❑Other ❑Delta — — --J — ❑ Public �� pprox. Depth', ❑Eastern Surface Seal installed by - --- -- State Work Done — ❑ irrigation 4 _ H.P. Repair Work Done i7 Type of Pump --= _ Seating Material (top 50') Well Destruction -1 Well Diameter F ' — public sewer is Filler Material (Below 50') — ------ ermitted if P Depth — �—� available within 200 feet.} REPAIRlADDlT1ON C DESTRUCTION C INo septic system TYPE OF SEPTIC WOflK: NEW INiTALLATiON ❑ _ Commercial Other +, Instailatlon will serve: Residence _Water table depth— -- Number of bedrooms, -�— — Number of living units:.— >/�p? Oft// No. Compartments — Character of soli to a depth of 3 feet: —�Gy Capacity — `,� TYPefMf9 Method of Disposal SEPTIC TANK L j � �� PKG. TREATMENT PLT. G ��//��ti � Foundation — f1L-s— Property Distance to nearest: Well 1_�— �t-- I --- Total length/size_—�� C JNo. &Length of lines — 2 property Line - — LEACHING LINE' Well 1� Foundation --_— FILTER BED l Distance to nearest: Number ; — Depth — a�Size _— 3 / — Line AQ ' SEEPAGE PITS z Foundations- Pr0� Skimps ❑ Distance to nearest: Well Foundation 1 DISPOSAL PONDS11 c _ t 1 have prepared this application and that the work will be done In accordance with San work for Joaqu(which th perm t ordinances, s issued, I shall no I hereby certify the natur I certify that in the performance of the wo rules and regulations a the San Joaquin Local He District. to Contractor's h subject to workman's compensa Home owner or licensed agent's signature certifies the following: " person in such manner as to become subject to work for which this perm Ws issued'fI shall employ ptors hiring or sub contracting srg employ any following' I certify that in the performance of the certifies the foNowing: " tion laws of California." The applicant must call for all required inspections. Complete drawing on reverse side. — Date:, _--. Title: Signed X ------w F— t OR DEPARTMENT USE ONLY Area pate Application Accepted by — + 2 Date } e. a Fin ial Inspection -by t� it r Grout Inspection by Additional Comments:1 ❑Mantec1 E. Hazelton Ave., P.O. B Manteca 823 7104 (2 Tracy 835-6385 Stk., CA 95201 ❑ Stk 466-6781 ❑ Lodi 369 362 ' Applicant -Return all copies to: Environmental Health permit/Services 160ox , CK # RECEIVED By DATE. PERMIT NO. FEE AMOUNT DUE AMOUNT REMITTED CASE{ INFO � g 1 � EH 13-24 [REV -"E5) � d EH 14-26 s + _ ,. ...-- ,►