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—iffiffiffilp-- - - APPLICATION FOR PERM1 SAN JOAQUIN LOCAL HEALTH DISTRICT a s' 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 y • PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) PERMIT NO.g q - DATE ISSUED l the rein Application is hereby madeth istrict for a CountyPOrdinance cNo. 549tfordse.wagesorlNo. 1862rforewell/pump described. PP and the Rules and Regulations of the San Joaquin Local Health District. �� Subdivision Name. [ C�� P Jab Address hone tl� a+SlbSE— Address- Owner's Name Phone Contractor's Name License No. TYPE OF WELL/PUMP IdORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ ❑ OTHER U 1 PUMP INSTALLATION SYSTEM REPAIR PROP. LINE SEWER LINES. DISPOSAL FLD. Q, DISTANCE TO NEAREST: SEPTIC TANK �— OTHER WELL _ PITS/SUMPS FOUNDATION 7 .. fi AGRICULT.URE..WELL CONSTRUCTION SPECIFICATIONS INTENDED USE TYPE OF WELL -PROBLEM AREA Dia. of Well Excavation Open, Bottom ❑ Manteca { Industrial .,4 U P ' —7 /-\ Dia. of Well Casing ` E ff y ❑ Domestic/Private-1 . ❑ Gravel; Pack roc 6- ❑ Public ❑ Other ❑ Delta Type of Casing Specifications Irrigation Approx. Eastern 5 ❑ p t. Depth Depth of Grout Seal. �- ❑ Cathodic Protection - _ I .�- ❑ Geophysical Type of Grout 1 s--• " Other kSurface Seal Installed by H P State Work Done y Repair Work Done G Type of Pump Sealing Material (top* 50') ►� rad Well Destruction U Well Diameter I r Depth Filler Material (Belo 50') piavailable permitted if public sewer is REPAIR/ADDITION (No septic tank or seepage lable within 200 feet.) TYPE OF SEPTIC WORK: NEW INSTALLATION �I { y l Other rciar Installation will serve: Residence K Comme— " ` �`p Number of bedrooms Water table depth. Lot"size"" Number of living units: �_ NumI : - Character of sail to a depth of 3 feet: No. Compartments Capacity ------ Type/Mfg .�, SEPTIC TANK ❑ Type/Mfg Method o.f"DT posal..__ Capacity PKG. TREATMENT PLT. ❑ TypelMfg Founda,e Property Line tion �- ❑ Distance to nearest: Well SEWAGE SYSTEM i DESTRUCTION Total-length/size i No. &•Length of lines Property Line LEACHING LINE I� Foundation FILTER BED ❑ Distance to nearest: Well 1. ' �� sI r Number � Depth- Size- r F--�erty'Line� _S �- SEEPAGE PITS Foundation SUMPS U Distance to nearest: Well i DISPOSAL PONDS ❑- r plication and that the work will be done in accordance.wi'th San Joaquin, county I hereby certify that I have prepared this app nature certifies the following: ,I�bertif subjecintthwo kman compe�sathonwork lawsfgf Calor ifornia•" ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. Home owner or licensed agent's signature person in such ,manner as to k. "1 certify thatlim the3pe'rformance of the'wor,k for which # permit is issued, I shall not employ si nature certifies the follow mg: '3r Contractor's hi 'ng or sub -contracting 9._ 1 e"dr in on reverse side. this permit is sued, I shall employ persons ��Uectrto workman'scompensationlaws of California.requi d nns Comp Date: The applic n call for Title: Signed XJ(�/ Stk..� _� D - 466-6781 R -DEPARTMENT USE ONLY Area D; ''► �r ,' , :.s -- ❑ Lodi 369-3621 f ; ., "�, ted..b -; Applica �n Accep y ❑ Manteca B23-7104'` e I Additional' Comments: Date Tracy 835-6385 I I Pit or Grout InspectionDate Stk., CA 95201 E, *toAve.,P.O. Box 2009, dFinal Inspection by - " Applicant - Return all copi Enviroental Health PermitlSer� vies0 PERMIT NO. - T { - cDAiE. RECEIVED BY AMOUNT REMITTED i - FEE BASE AMOUNT DUE G'�-.0 ..�- (J •l-' J..V^c'...__R��y � INFO .;., """: �._..« �.,• ...k ;�'° 10182 500 4 i EH 13-24 REV. 10/82 7 -� 14-26 -