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APPLICATION FOR PERMIT ` z SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA PAYMENT Telephone (209) 466-6781 RECEIVED PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) � � �� .af�QWNW�=; �ation is Application is hereby made to the San Joaquin Local Health District fora permit to construct ell/pu install the work 1V1_Je9H � J�aquin made in compliance with San Joaquin County Ordinance No"549 for sewage or No. 1862 far well) ump and the Rul �J Local Health District. 2(3 _.p 7f?--(e i ENVIRONMENTAL HEALTH DIVISION rC�C Lot Size 9 0 m--rePM e� ;ne city ' Job Address f Y ' p ,} C`v Sfi�Q`z��4evi i7 V11cr zj Phone Owner's Name r M C Address G�rGw tJ c c90 f , ,,,,•� rAP1C)/a off 6-F, c'/t 4T11 Itl `fin o License No.NR Contractor S Address d�d Phoneyf 8�� TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT LJ DESTRUCTION ❑ i - SYSTEM REPAIR El DISPOSAL PUMP INSTALLATION ❑ t DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL i � ITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS i�clte ❑ Industrial ❑ Open Bottom ❑ Manteca Dia" of Weill Excavation r`A u C5 Dia.-of Well Casing Tracy Type of Casing C-� Specifications�� Domestic/Private Gravel Pack 25' �� Type of Grout fly'[ Ce C'11 - l`1 Public j l ! Other ❑ Delta Depth of Grout Seal "y �Vt r` eer O I i Irrigation Z-Q� Approx. Depth l I Eastern Surface Seal Installed by�� iH p State Work Done Repair Work Done ❑ Type of Pump Well Destruction 01 Well Diameter `� '�G a Sealing Material (top 501) n! CA, tel Depth Filler Material (Below 501 I TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIR/ADDITION 1 1 DESTRUCTION I I (No septic systhin m permitted if public sewer is availabl eetJ Installation will serve:' Residence— Commercial— Other f r Number of living units: Number of bedrooms Water table depth Character of soil to a depth of 3 feet: I ❑ Type/Mf Capacity No. Compartments SEPTIC TANK 9 PKG, TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line I I M LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS l 1 Depth Size — Number SUMPS Ll Distance to nearest: Well Foundation 'Property Line DISPOSAL PONDS - - r 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 regulations of the San Joaquin Local Health District. Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work far which this permit is issued, 1 shall not signature N employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting certifies the following: 111 certify that in the performance of the work for which this permit is issued,1 shall employ persons subject to workman's compensa- tion laws of California." The applica^.*,t t callor all qui ed inspections. Complete drawing on reverse side. Signed X rJz ;';.',` �4 Title: 90 Date: 90 . A 4' luo� 'z}1� DEKA NT USE ONLY JJ . : ` Date 6 N �d Area Application Accepted by Pit or Grout Inspection by Date— Final inspection by Date 3 A Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca a23-7104 ❑ Tracy 835-6385 Applicant'- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, 5tk., GA 95241 4 CK RECEIVED BY DATE PERMIT No FEE . INFO AMOUNT DUE AMOUNT REMITTED CASH ♦ EH 13.24(REV"riH5) EH 14-26 t