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s.._ a ".�^ .. ,... - � --_., il . .tx v'....�..�t-ri�sM.F:eLfi��aSq�.•f�� -r s rq � APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE LTON AVE., STOCKTON, CA r: spy Telephone (209) X166-6781ZVI � PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) LvT ViN �U� in �~ Application is hereby made to the San Joaquin Local Health Distract for a perm it t 7862 forto cwelUpump and the Rules and ll the work 'Reg�ti�c1 the Son Joaqu made in compliance with San Joaquin County Ordinance No.543 foraewage '_ocal Health District. r x Job Addruss — 9 2 5 �okN� a�� I.� City Lo i Lotslze , Phone • �. � + �� Owners NameAddress ii{ WELL ❑ D �Kv nroLicense No2WleTtttsBddress Contractor DESTRUCTION ❑LiWELL REPLACEMENT TYPE OFWELL/PUMP: 7�•*��'r 3 A kF { PUMP INSTALLATION ❑ SYSTEM REPAIR 13OTHER ❑ a DISTANCE TO NEAREST: SEPTIC TANK SEYIER LINES DISPOSAL FLD. PROP LINE } FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS , INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia.of Well Casing ❑Industrial ❑Open Bottom ❑ Manteca Dia.of Well Excavation Type of Casing Specifications C] Domestic/Private ❑ Gravel Pack ❑Tracy _' ❑ Public ❑ Other C Delta Depth of Grout Seal _ T1ipe of f Grout rox. Depth C3 Eastern Surface Seal Installed by E S-t'• � El irrigation --App State Work Done_ *` of Pump H.P. f9k i' i'a Repair Work Done C] TYPe Sealing Material (top 50'1 t, Well Destructior C Well Diameter Depth — Filler Material(Below 50'1 AIR/ADDITION C DESTRUCTION C (No septic system permitted if public sewer is r TYPE OF SEPTIC WORK: NEW INSTALLATION available within 200 feet.) Ini"rAstion will serve: R idence Commercial_ Other t .. Number of Irving units:77 Number of drooms Water table depth Character of soil to a depth of 3 feet: ^ Capacity No. Compartments: SEPTIC TANK Type/Mfg . Method of Di I PKG. TREATMENT PLT.❑ "f y x - Distance to nearest: Well n0 Foundation1— Property Line _ Tot1l length/size LEACHING LINE ��a &Length of lines ��y � r' FILTER BED C Dist.nce to nearest: Well. �yGU Foundation Property Line Number iL ' SEEPAGE PITS ue�Depth = ---Size —1 SUMPS C Distance to nearest: Woll — Foundation Property Line r ' DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the wort,will be done in accordance with San Joaquin county ordinances,state laws and u rules and regulations of the San Joaquin Local Health District. Home owner or licensed agenot nt's signature certifies the following: "I certify that in the performance of the work for which this permit is issued,I sf Pn= employ any person in such mennur as to become subject to workman's compensation laws of California."Contractors hiring or sub contracting ei9 r- ertifies the folbwing:"I certify tFtat In the performance of the work for which this permit is issued,I shall employ persons subject to workman's compena JA ` }� tb ws of Celitom The epplic u cell all r wired i ti 6mplete drawing on re me side. ^ p�\T^ 11 �+, Date: p Title: _x ri 9, Signed f� a FOR D'ePARTMENT USE ONLY ;y ; Date — — — G' Area�- c } Application Accepted by , Date nate �F.nalon by or Grout Inspection b or Additional Comments 'i ❑ Stk 4666781 ❑ Lodi 369.3621 EJ 823.7104 C Tracy 835.5385 '!? Applicant• Return all copies to: Environmental Health Permit/Serv*.-as 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95701 1. CK RECEIVED BY DATE PERMIT NO. . 'EE AMOUNT DUE AMOUNT REMITTED INFO l�l l EH 13-24(REV.�'i'� T ('15114 EH 14 1C