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T APPLICATION SAN JOAQUlN FOR PERMIT LOCAL HEALTH DISTRICT E. HAZELTON AVE., STOCKTON, CA ' Telephone (209) 81 PERMIT EXPIRES 1 YEAR F ROMDATEISS { Application ISSUED pp cation (CO +s hereby made to the San Jo aquin Local Health District(Complete in Triplicate) made in compliance with Local Health San Joaquin County tr+ct for a It Permit h District. tY Ordinance It p mit to construct and/or install the work herein described. 7 l for sewage or No, 1862 for well/pump and the Rules and Regulations of the San Joaquin This application is_.� Job Address X ![J+ q n 1 City ' Owner's NameIIII Lot Size y+y PM Contract is NameP ^ dress 9� V Phone �. TYPE OF W cense No WELL/ LMP: lr�._,NEW,,WELL�❑ ' * t-�PUMP INSTALLATION ❑ - -WELL_REP.LACEMENT ❑ Ph no e G 6 DISTANCE TO NEAREST: SEPTIC TANK # SYSTEM REPAIR Q DESTRUCTION C3 e - SEWER LINES l OTHER ❑ [A FOUNDATION l l DISPOSAL FLD. �V INTENDED USE ~ AGRICULTURE WELL � PROP. LINE TYPE OF WELLi WELL AREA ~ OTHER WELL� PITS/SUMPS ❑ Industrial �� Q Open Bottom CONSTRUCTION SPECIFICATIONS ❑ Domestic/Private ❑ Man_ Dia. of Well Excavation ❑ Gravel Pack ❑ Tracy ❑ Public F Type of Casing Dia. of Well Casing ❑ Other ❑ Delta ❑ Irrigation,, F s Depth of Grout Seal Specifications v +�Approx. Depth Repair Work Done by &V� -of^Pum P ❑ Eastern Surface Seal Installed b Type of Grout ' Wall Destruction p �— H.P. y ❑ Well Diameter State Work Done Depth 3 Sealing Material (top 50') TYRE OFzSEP7IC WORK: Filler Material (Below 501) I INSTALLA7lpN REpgIR/ADDITION ❑ DESTRUCTION Q (No septic system Residence Commercial ' permitted if public sewer is 1-0 Number of living units _ Others available within 200 feet.) Character of soil to a depth of`3 feet: of bedrooms SEPTIC TANK' `?KG. TREATMENT PLT 18 Type/Mfg Water table depth O - y ,t Capacity_,&-90-1— No. Compartments r" Distance to nearest:. Wel Method of Disposal 7c Foundation ' Property Line LEACHING LIE' --�P"INo. & Length-of lines FILTER BED. Total len t ❑. Distance to nearest .yyep Foundation s h/size SEEPAGE PITS ' '-+ 1 ��-- Property Line, Depth i y _SU MPS Size , ❑ Distance to nearest: Number .. DISPOSAL PONDS; ❑ Wel) 1 Foundation � Property Line hereby certify that I have prepared this application and that the work will be done in accordance1With San Joaquin coup ordin rules and regulations of the San Joaquin Local Health District. Home owner or licensed agent's signature tY ances,.state laws, and er l0 an g certifies the following: "f certify that in the performance of the work for which this permit is issued, I shall not p Y Y person in such manner as to become Subject to workman's compensation laws of California."Contractors h Ing_or sub-contracting signature certifies the following: "I certify that in the performance of the work for which this on la is issued, I shall em to tion laws of California.,, j p P Y persons subject to compensa- The applicant all for al required in ctions. Complete drawing on reverse side. w Signed _ Title: -- Date' Application Accepted by C N FOR DEPARTM NT USE ONLY 1 Date Z- �-� Area fit 4t GTout IRSpection by c tit Date _Q p y�,_ Final Ins Inspection b Date Additional Comments: 4 ❑ Stk 466-6781 ' ❑ Lodi 369-3621 ❑ Manteca 873-7104 El Tracy 635-6385 { Applicant- Return ¢all-copies to:-Environmental-Health-Permit/Services 1&01-E:-Hazelton Aye.-�P.O:-Box 2009-Stk,•GA-95201. ,M I P i r FEE e I ; ��Ou��Dui PtMOUL�T�em«�D CAS41'�, � RECEIVED�`(. ,� �`.oA�E p>:R►�,�"1�0. :4 . 1��4