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t AP�. .ATiOM FOR PERM;I SAN JOAQUiN LOCAL HEALTH DISTRICT i 1601 E. HAZELTON AVE., STOCKTON, CA _ F Telephone (209) 466-6781 PERMIT NO. I I PERMIT EXPIRES 1 YEAR FROM DATE ISSUED DATE ISSUED S (Complete in Triplicate) Fribekation is hereby made" to the San Joaquin Local Health District for a permit to construct and/or install the work herein d. This application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well the Rules and Regulat ons the-SAn Joaq in Local Health District.. /pump Address r s Name ivision Name Address _Fractor's Name Phone License No, � Phone Z 6E• $�-? 1` OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT 0�1 I � ❑ DESTRUCTION❑ (/�} PUMP INSTALLATION SYSTEM REPAIR 1 INCE TO NEAREST: SEPTIC TANK ❑ OTHER ❑ r� �^ SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL V INTENDED USE PI75/SUtiPS TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Idustrial Open Bottom mastic/Private U p ❑Manteca Dia, of Well Excavation r1rigation blic ❑Gravel Pack ❑TracyOia, of WeIT Casing ❑Other Delta Type of Casing Approx. ❑Eastern Ithodic Protection Depth Specifications ophysical Depth of Grout Seal ,,her Type of Grout Work Done ❑ Type of Pump H P i Surface Seal Installed by State Work Done estruction ❑ Well Diameter Sealing Material (top 501) Depth Filler Material (Below 501) I,OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION 74-1<o septic tank or seepage pit permitted if public sewer is tallation will serve: Residence `"'---conmercial Other available within 200 feet.) ber of living units: --_1_.__ Number ofpedrooms C} Lot szeioZ , , racter of soil to a depth of 3 feet: — f nO f , (� C TANK TWater table depth I V C Type/Mfg CapaciNo. Compartments Z-- ty �TREATMENT PLT. ❑ Type/Mfg Capacity E SYSTEM P y _ Method of Disposal ESTRUCTION [] Distance to nearest: Well r Foundation -34-1 Property Line f ING LINE FfT*- No. b Length of lines 3 — T Total length/size f R BED ❑ Distance to nearest: Well foundation Property Line T SE PITS rg, -Depth �1 Size 3 �y Num er 3 iJ Distance to nearest: Well Foundation _ Property Line IAL PONOS ❑ � � � ( . FSby certify that I have prepared this application and that the work will be-done in accordance with San Joaquin county inces. state laws, and rules and regulations of the San Joaquin Local Health District. }weer or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this t is issued, I shall not employ any person in such manner as to become subject to workman compensation laws of California." actor's hiring or subactin si }>ermit is issued, I shat hal empl gnature certifies the following: "I 'certify that in the performance of the work for which persons subject to workman's compensation laws of California." 'Plic f ust ca for ed inspections. Complete drawing on'reverse side. �f 1 X Title- Date: 44 4f-Date: VVI JI FOR DEPARTMENT USE ONLY Application Accepted by Area E] Stk 466-6781 Additions} Comments: odi 369-3621 r Pit or Grout Inspection b ` IK Date C] Manteca 823-7104 Final Inspection by Date � (� Tracy 835-6385 ant - Return all copies o: . Envir tal Health Permit/Services 1601 Haz It Ave,, P_0. Box 2009, Stk., CA 95201 r FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY INFO GATE PERMIT N0. j I�