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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE.; STOCKTON, CA` " A Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROMDATEISSUED t (Complete in Triplicate) I and/or install the work herein described.This application is Application is hereby made to the San Joaquin Local Health District far a permit to construct or No. 1862 for well pump and the Rules and Regulations made in compliance with San Joaquin County Ordinance No.549 for sewage of the San Joaquin Local Health District. e '1f Lot Size PM i City Job Address �] Owners Name - Ad ass Phon `7trLicense No. �.. Contracxor's Name s� + , WELL+REPLACEMENT ;"DESTRUCTION ❑ .� " TYPE ORWELL/PUMP: h = '(SEW WELL ❑ OTHER ❑ r ' PUMP INSTALLATION ❑ SYSTEM REPAIFt E3-- � r �. ,'1 - �.i 3 - 1 , * r �� 1 DISP`OSAI-IFLD.,, , PROP.+LINE.v SEWE LINES �.=y"— � c DISTANCE TO NEAREST: SEPTIC TANK= ' AGRICULTURE WELL _ _ � 711ER:WELL �_ .4 PITSISUMPS'"� ��Ol1NDATIONLt k, INTENDED USE TYPE OF WELL PROBLEM "'CONSTflUCTION SPECIFICATIONS ,- �. Dia..oWe f I15Casing ❑ industrial El Open Bottom DManteca g' Dia, of Well Excavation " 'Type of Casing Specifications 1 e} L] Domestic/Private L1Gravel Pack C Tracy ElDelta +. Depth of Grout Seal Type of Grout I ❑ Other 1 El Public ' urface Seal Installed by" _--Approx. Depth ❑ Eastern ❑ Irrigation ;°PP r t ` -�" =-�- State WorkNDone j I Repair Work Done ❑ 1Type,o PumpytSH,P.} Well Destruction ❑ `GWell Diameter 'Sealing Material (to 50') ` Depth Filler Material {Below 50'1 C TYPE OF SEPTIC.WORK. .NEW INSTALLATION REPAIRlADDITIDN;❑ DESTRUCTION ❑ a'vailabpelw litri?00#eetem it?ed if Installation will serve Resident e - Commercial Wer c Number of living units: Number of bedrooms { Water table depth Y Character of soil to a depth of 3.feet: r �� No. Compartments R 1 SEPTIC TANK A Type/Mfg 1; Capacity _ k Method of Disposal PKG. TREATMENT PLT- ❑ r j + � ^Distance to nearest: Well— '- Fopndation Poperty Line i No. & Len Length of lines A Total length/size LEACHING LINE g ��'� +�Foundation — Property"Line , FILTER BED Q Distance to nearest: Well } l i Number SEEPAGE PITS' ❑ Depth Size tt r _ J Property;Line- i SUMPS � Distance to nearest: Well Foundation DISPOSAL PONDS" El I hereby certify that I have prepared this application and that the work wi11 be done in accordance with San o q county ordinances, state laws, and rules and regulations of the San Joaquin Local Health"District. `� -�; } Home owner or licensed agent's signature certifiesi'the.following:;""Ircertify.that-in;the•performance of the work for which thls�ermtt 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 Fpn�acti%g signature certifies the following:"I certify that in the perform nca of the work for which this permit is issued;I shall'employ persoAr subj f x to v�rorkmari's;compensa-� tion laws of California." ;'�h;; ^. `\ r The applicant mu I for all requi ed ins ctions. Complete dra Ii --4evR se side. .�J �� Signed X -'` Title: t �J Date: FOR DEPAEtTMENT'U5E ONLY a T k _ Date Area Application'A cepted.by a -�* n P` Date Final Inspection by Date Pit or Grout inspection by ; , lddit101 81_COmfn nts: ' O Stk 4W Ml ❑ LWi 361-3621 ❑ Manteca :823-7104 ❑ Tracy 835x6365 Applicant- Return all copies to: Environmental Health..Permit/Services 1601.E. Hazelton Ave:, P.O. Box 2009; Stk., GA 95201 CK* RECEIVED BY DATE PERMIT NO." "IFEE NFO AMOUNT DUE AMOUNT REMITTED CASH s' + 1REV.10!93} 4 EH 13-24 "" Imo! ' ff6 1 d EH 14-26 ! _.