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SAN JOAQ <br />UIN LOCAL HEALTH DISTRICT <br />1601 E. HAZELTON AVE,, STOCKTON, CA <br />Telephone (209) 466-678, <br />PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />I.,Urrtpiete In TrjpliCate) <br />made <br />Application <br />compliance wieby th San Jade to the aqu nnCounty Ordquin inance No. 549 for sev cal Hedith District for a <br />Permit to construct and/or install the work herein described This a <br />Local Health District, age or No. 1862 for well/ <br />Rump and the Rules and Regulations of the ppliJoaq n <br />p San Joaquin <br />Job Address ,, �Q <br />City,Al `+I Lot Size <br />Owner's Name a fAt , U•; ` '� l Drs- PM <br />Address 4 <br />Contracto I /� �r, f �— Phone 31 b <br />TYPE OF WELL/PUMP: Address �; 1 ✓! // <br />NEW WELL Q License IYo. _ice Phone -f3 <br />PUMP INSTALLATION ❑ WELL REPLACEMENT <br />DISTANCE TO NEAREST: SEPTIC TANK SYSTEM REPAIR [j DESTRUCTION p <br />-�- SEWER LINES OTHER <br />FOUNDATION AGRICULTURE WELL C DISPOSAL FLD._ PROP. LINE <br />INTENDED USE TYPE OF WELL �-- OTHER WELL PITS/SUMPS <br />❑ Industria! PROBLEM AREA <br />❑ Domestic/Private <br />❑ Public <br />11 Irrigation <br />Repair Work Done ❑ <br />Well Destr ction <br />,u��%;cr y <br />rlif <br />TYPE OF SEPTIG.3Nna e <br />❑ Open Bottom <br />71 Grave! Pack <br />❑ Other <br />---_ <br />L3Manteca <br />❑ Tracy <br />❑ Delta <br />---Approx. Depth ❑ Eastern <br />Type of Pump <br />Well Diameter <br />Depth <br />AI CYnY . <br />CONSTRUCTION SPECIFICATIONS <br />Dia. 11 Well Excavation <br />TYPO of Casing_ AjD�l1l <br />Depth of Grout Seal <br />Surface Seal Installed by <br />H. P. <br />State Work Done <br />Sealing Material (top 50') <br />Filler Material (Below 50") <br />--4 IVIN U HEPAiR/ADDITION ❑ <br />Installation will serve; Residence : Commercial . Other <br />Number of I;-;--� <br />g urns. Number of bedrooms <br />Character of soil to a depth of 3 feet: <br />SEPTIC TANK ❑ Type/Mfg <br />PKG. TREATMENT PLT. ❑ <br />LEAC"ING LINE <br />FILTER BED <br />Distance to nearest: Weil <br />Dia. of Wel! Casing <br />Specifications <br />Type of Groutt?keo <br />(No septic system permitted if public sewer is <br />available within 200 feet ) <br />---Water table depth - <br />- Capacity No. Compartments <br />Method of Disposal <br />Foundation __ Property Line , <br />Q No. & Length of fines _ <br />❑ Distance to nearest: ~— -Total length/size <br />Well <br />Foundation _ Property Line <br />SEEPAGE PITS ❑ Depth <br />Size Number <br />SUMPS ❑ Distance to nearest: Well <br />DISPOSAL PONDS L]Foundation Property Line <br />1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br />rules and regulations of the San Joaquin Local Health District. <br />Home owner or licensed agent's signature certifies the following: "'I certify that in the performance of the work for which this <br />employ any person in such manner as to become subject to workman's com permit is issued, I shall not <br />certifies the following:pensation laws of California." Contractor's hiring or sub -contracting signature <br />"I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br />tion laws of California." <br />The applicant us# gall for all rgpuirBdanspeQrions. Complete drawing on reverse side. <br />Signed X <br />� T� e: � dry <br />L Date: <br />FOR ARTMENT USE ONLY <br />Application Accepted b l` _ <br />Pit or Grout Inspection by Date 4 Area <br />Date Final Inspection b - �✓ <br />Additional Comments:Date 4 1 44 <br />❑ Stk 466-6781 ❑ Lodi 369- Q Manteca 823-7104❑Tracy <br />835-6385 <br />Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br />+ EH 1324 (REV. i r e <br />EH 14-26 <br />