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F � { APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA f—", / Telephone:(203) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED, . Orr (Complete in Triplicate) ll the work .This cstiOn is Application is hereby made tothe San Joaqui O dinalnce No.549 far sewagHealth District for a pe or INo. 1862 for well/t to construct dpump and he Rules and(Regulations of the Saan1 Joaqu n made In compliance with San Joaquin County Local Health District. ; ,wrLot Size I City r P i � ' f1A y 3 b b -� d ILM e-- s Job Address 4•x r' ��' _ ,,,,// � Phone 3 3 C� Owner's Name _ r i0.�`°�— Address — J A'� Address License No.__—_Phone ' Contractor r Y�`Q �O i TYPE OF WELLIPUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ ZOO i DISTANCE TO NEAREST: SEPTIC TANK _ — SEWER LINES DISPOSAL FLD. PROP. LINE . FOUNDATION AGRICULTURE WELL OTHERCWELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS'" J Dia. of Well Casing ❑ Open Hotton ❑ Manteca Dia. of Well'Excavation ❑ Industrial Specifications if Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing _-,� Type of Grout W Cl Public ❑ Other-.-r --0'Delta--*"'�'�`"��gout Seal � Irrigation 2VLApprox.1Depth ❑ Eastern SuHaac'S al Installed by e I H.P. State Work Done Repair Work Done ❑ Type of Pump Well Destruction Q Sealing Material (top 50'1 Well Diameter ' DIepth� !I� Filler Material {Below 50'1 TYPE OF SEPTIC WORK: NEIN INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial x 30the�try? Number of living units: Number of bedrooms Water table depth Character of soil to a depth of 3 feet. No. Compartments i Capacity.��- SEPTIC TANK Type/Mfg _ Method of Disposal.. PKG. TREATMENT PLT. ❑ f 300 'Foundation sa 3 Property Line O - ' Distance to nearest: Well_-� � � IF 0 Tot I length/size L LEACHING' N�E-1�� o• &Length of.lines �— k oundation Property Line FILTER BED ElDistance'to nearest: Well Cize I 0. Number ----SEEPAGE PITS---- ---�--D �t ! ❑ Distance to nearest: 'Welt r►daVon Property tine SUMPS DISPOSAL PONDS .. ❑ ,-y �. -- _- I I hereby certify that I have prepared this application and that the work will tidone inn 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 cergfy'#hat in the performance of the work for which this permit is issued, I shall not ' employ any person in such mariner as to become subject to workman's:compensation laws of California."Contractor's hiring or sub-contracting signature certifies the following:"I certify that int he 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 must call for all required inspections. Complete drawing on reverse side. p�� Title: Date: !/ Signed ' DEPARTMENT USE ONLY 4r ,` /� , _�y11-J Date T Area. V _ r r C. Application Accepted by Final Inspection by D �PTI Pit or Grout Inspection by !Da e � q Additional Comments: gerr E t ❑ Stk 466-6781 Lodi 369- 1 ❑ Manteca 823-7104 ❑ racyZ. Applicant Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Boxx 2009, Stk , CA 01 ; r F f �w, -�.� ��t 2 RECEIVED 8Y DATE PERMI7'-NO. t FEE AMOUNT DUE AMOUNT REMITTED CASH - ,� )NFO �� +EH 13-241REV.1/65) EH 14-26 (/