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APPLICATION FOR PERMIT- PAYMENT . SAN �OAQUIN LOCAL HEALTH DISTRICT RECEIVED tisol E HAZE, ON AVE., STUCKTON, REC Telephone (209) 466-67$1 MAY 1 0 1A 0 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED SAN JOAQUIN COUNTY (Complete in Triplicate) PlJBLIC HEALTH SERVICES ication is o the San Joaq er a a or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin ode t uin Local Health District for a9ermit to construct and/or instElbliFlR R �S ApplicE is hereby m Ordinance Na.549., C rr made in compliance with San Joaquin County _ :r PM Local Health District. Stockton Lot Size Job Address St, d Walker Ave. City 465_3451 Address N. phone Sinclair Ave. (805 Owner's Name 278907 Phone 871-6200 13 ersf i el d CA License No._�---- Address DESTRUCTION ❑ Contractors-0 WELL REPLACEMENT ❑ '' NEW WELL ❑ OTHER LDj TYPE OF WELL/PUMP: SYSTEM REPAIR ❑ PROP. LINE W PUMP INSTALLATION ❑ 500E DISPOSAL FLD. DISTANCE TO NEAREST: SEPTIC TANK — SEWER LINES .�--- OTHER WELL PITS/SUMPS FOUNDATION ---- AGRICULTURE WELL ln_ I, INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS pia. of Well Casing 8 5 8 -- Dia, of Well Excavation {� Industrial D Open Bottom ❑ Manteca Steel Specifications Type of Casing I ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy yp Type of Grout _ QQ Other Monitor F1 Delta Depth of Grout Seal 10 f`] Public Surface Seal Installed by Cr I Irrigation Approx. Depth l I Eastern State Work Done r' of Pump �Or= H.P. Repair Work Done ❑ Type 119 Sealing Material )top 50') Welt Destruction ❑ Well Diameter Depth Filler Material (Below 501 t TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION t I DESTRUCTION l i afvailabllerwthin 200 feet.)m per if public sewer is f: Installation will serve: Residence_ Commercial Other 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 PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line j l LEACHING LINE CI No. & Length of lines Total length/size f FILTER BED ❑ Distance to nearest: well Foundation - Property Line SEEPAGE PITS l I Depth Size Number .,} SUMPS L1 Distance to nearest: Well Foundation Property Line ' DISPOSAL PONDS ❑ 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 a rules and regulations of the San Joaquin Local Health Di§trict- +I Home owner or licensed agent's signature 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 as to become subject to workman's compensation laws of California." Contractors hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applicant m for all re ed spections. Complete drawing on reverse side. Signe Title: g�� T Date: FOR DEP R'r11i1E ONLY � Date Application Accepted by 6T Date ` z �6T Pit or Grout Inspection by Date Final Inspection by y Additional Comments: rt dated March 2 1990 and RW C eller from G. Reents ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ 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 FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE gM31T' 4�INFO �/.EH 13-44"' Ev.1/H 51 -o. � - EH 14-2e� - 11