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APPLICATION FOR PERMIT <br />SAN JOAQUIN LOCAL HEALTH DISTRICT <br />1601 E. HAZELTON AVE., STOCKTON, CA <br />Telephone (209) 4WI5781 <br />PERMIT. EXPIRES 1 YEAR FROM DATE ISSUED' 'T of <br />(Complete in Triplicate) . ,.z�. �;: t" . t, .. .IL` .'.' <br />r'Local Health <br />Application is hereby made <br />to the <br />Sa County Ordinance No. ication 'Is <br />D549rfor sewage or permit <br />construct <br />n Joaquin1862 forwell1pump and the, R41es and Regulations ^ f the Sa Joaquin <br />mwith ade in compliance <br />Local Health District. I <br />;. PM <br />19950h�OC1c1=Fn _r��S' `ICity- Lot size77 <br />Job Address <br />L V Address 1�"t f ��' r r �O _ _� Phone <br />Owner's Name 1-3 s <br />� p!)sillee5DrNlit�Co�PAddress'.tr.lhd�—License No. � •z- - Phone <br />Contractor DESTRUCTION L - <br />TYPE OF WELL/PUMP:NEW WELL YWELL REPLACEMENT G <br />PUMP INSTALLATION - 11 <br />SYSTEM REPAIR 7 OTHER <br />DISPOSAL FLD. PROP, LINE <br />DISTANCE TO NEAREST: SEPTIC TANK IOO SEWER LINES — PITS/SUMPS ' <br />_ AGRICUUTIIRE WELT''" --••_'-OTHER WEL-L - <br />-FOUNDATIONr "- <br />INTENDED USE TYPE OF WELL ~PROBLEM AREA CONSTRUCTION�SPECIFICATIONS <br />'u Industrial Y, Open Bottom ❑ Manteca Dia. of Well Excavation <br />Dia. of -Well Casing d <br />T of Casin i- ���� 1 Specifications <br />k X Domestic/Private ❑ Gravel Pack C Tracy Type g' <br />.. d dGe.t►14dt <br />t Cl Delta <br />Depth of -Grout Seal _ S� Type of Grout <br />G Public C1 Other <br />X Irrigation Approx. Depth L Eastern Surface State Work Done Seal Installed by_ <br />` Repair Work Done a Type of PuH P mp r< <br />l Well Destruction ❑ Well Diameter Sealing Material (top 56') <br />Depth Filler Material (Below 50') <br />l TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/AUDITION O DESTRUCTION '❑ available within 200 feetc system .) <br />if public sewer is <br />Installation will serve: Residence __ _' Commercial <br />Number of living units: Number of bedrooms — <br />Character of soil to a depth of 3 feet: <br />SEPTIC TANK C Type/Mfg <br />PKG. TREATMENT PLT. <br />Distance to nearest: Well <br />Other <br />Water table depth <br />Capacity " I No. Compartments _ <br />T Method of Disposal - <br />Foundation . Property Line <br />LEACHING LINE :1 No. & Length of lines <br />FILTER BED 7 Distance to nearest: • Well _ <br />Total <br />Foundation —.Property Line . f <br />Size Number <br />SEEPAGE PITS E] Depth z Property Line <br />SUMPS d Distance to nearest: Well Foundation <br />DISPOSALPONDS <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 />' nature <br />Home owner or licensed agents signature certifies the following:'i certify that in the performance of the work for which this permit is issued,, I shat not <br />employ any person in such mann as <br />to t performance ubje of the work for which compensation <br />9 permitl'ssu�of rfoshetl emplayapersonsctoes rsubject t workman's aomPansa <br />ws <br />certifies the following: "I certify <br />tion laws of California." <br />The applica usr,call f at ared inspections. Complete drawing on reverse side. <br />Tale: Date. 1--0 <br />Signed <br />FOR DEP�IRTMENT USE ONLY a <br />C Date — t--�� Area — D/ �j- <br />Application Accepted by� O <br />r� ate <br />Pito Grout nspection by - Date j Final Inspection by <br />Additional Comments: <br />C' Stk 466 -Mi ❑ Lodi 369-3621 ❑(Manteca ffi3 7104 ❑Tracy 83rr6385 <br />Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95207 <br />ffCASH RECEIVED BY. DATE PERMIT NO - <br />FEE AMOUNT DUE AMOUNT REMITTED <br />INFO <br />♦ EH 7321 (REV. 1/65i <br />EH 14-24 <br />�r <br />