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APPLICATION FOR PERMIT SAN JOAQ^UIN LOCAL HEALTH DISTRICT /A/0 "„ 0 1601 E. .AJZELTON AVE., STOCKTON, CA �j le Telephone 12191 46676781 k y PERMIT EXPIRES 1 YEAR FROM DATE ISSUED f 1�. ... (Complete in Triplicate)- <” oaquin Local health District for a permit to construct and/or install the work herein described. This application is Application is hereby made to the San J j e or No. 1862 for welllpump and the Rules and Regulations of the San Joaquin made in compliance with San Joaquin County Ordinance No:549 for sewag + Local Health District: HJT , ' r, r ' PM i i Job Address _f� �� r� w A v� Cty Lot Size c Nve�t, __ J (jl A.ddre"ss Phone Owner's Name ��// t �. t � a� �C ,� License No.44 s1 - hone_ k Contractor fidress _ TYPE OF WELL/PUMP: NEW WEL`,�."> WELL REPLACEMENT �- UES7RUCT10N -i7J` PUMP INSTALLATION, _ _5Y.STEM SYSTEM-REPAIR-0 OTHER ❑ _ s DISPOSAL FLD. - "`•PROP. LINE DISTANCE TO NEAREST: SEPTIC_TANK-, d-��SEWER LINES z - s - -- -_- FOUNDATION �AGRICULTURE WELD L iD t - OTHER WEL PITS/SUMPS 1 INTENDED USE '"TYPE OF WELL -PROBLEM AREA ` CbNSTRUCTION\SPECIF-ICATIONS " ry —_ - Dia. of Well Casing ❑ Industrial _❑ Open,Bottom - ❑ Manteca Dia. of Well Excavation o - Type of Casing Specifications [,Id 13omestiO/Private µ ❑-Gravel Pack ❑ Tracy Type of Grout LD Public ❑ Other ❑ DeltaDepih of Grout Se al F ❑ Irrigation I � pprox. Depth ❑ Eastern ` Surface Seal Installed by fr-^ A — _ State Work Done Repair Work Done O Type of Pump —� - H•P- '� Well Destruction Ll Well Diameter .—Sealing Material ltop 50'I : Depths Filler Material (Below 50') n TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ 4 REPAIR/ ❑. (No septic system permitted it public sewer is t . y±✓ ( availableithin 200 feet. wl .� F I a ,o Other k f 1 Installation will serve: Residence Commercia; v t _3 ,., Number of living units: i Number of bedrooms �� F c 2> � ''� 1. - i f,r Water table depth Character of soil to a depth of 3 feet: 1 '' f Ca acuy I A No. Compartments SEPTIC TANK I ❑ Type/Mfg p :f � _ ".:--- �� fj Method of Disposal PKG. TREATMENT PLT. ❑ I Distance to neares: - Well Foundation Property Line �� Total length/size I, LEACHING LINE El No & Length of lines r I Property Line . FILTER BED,- ElDistanceto nearest: -Well Foundation Number SEEPAGE PITS ❑ Depth Size EU r .Property Line F SUMPS„ r- ❑. Distance to-nearest...—d�.Well -- Foundation W �—F ~ r--DISPOSAL PONDS❑ I hereby certify that I have prepared this application and that the work will be done in ac -dance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. I - ensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, Home owner or lick shall not 1 rkman's compensation laws of California."Contractor's hiring or sub-contracting signature employ any person in such manner as to become subject to wo certifies the following:"I certify that in the performance of the work for which this permit is issued,1 shall employ persons subject to workman's compensa-, t tion laws of California." 1 . .. ..-� p e The applicant must cell= or a6 re wired inspections. Complete drawing on revers e.0. Vit* Title: - Dater Signed Ii .FOR-DEPARTMENT USE ONLY / L4 r Date � Y3G Area 4 ,fT��. Application Accepted by Final Inspection by Date Pit or row I spection byDate .3 Additional Comments: Ll Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823 7104 ❑ Tracy $35 fi385 Applicant- Return all copies to: Environmental Health Permit/Services 1601,E. Hazelton Ave., P.O. Box 2009, Stk., CA,-'95201•:, ' . CK RECEIVED BY DATE PERMIT'NO. FEE AMOUNT DUE' AMOUNT REMITTED CASH �./ * INFO /3 �S_ rS b w �s EH 13-241REV.1/851 wP• - ' \£H 14-28 - -