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APPLICLITION FOR PERMIT I' SAN JOAQUINOLOCAL.HEALTH DISTRICT 1601 E:!RAW-i ON AVE:, STOCKTON, CA PA� P � �1ti Telephone (209):466-d781 PERMIT EXPIRES 1 YEAR`FROM DATE ISSUED OCT 0 8 (Complete in Triplicate) P SpppAN'J+7AQ�JfN GOI Application is he+eby made to the Sari Joaquin Local Health District for a permit to construct and/or �oe . +YTttis application is ' I defihe San Joaquin made in compliance with San Joaquin County Ordinance No..,649 for`seWage or No- 1862 for welklpump IVISION Local Health District. Job Address U4 6 as� � Or�i City `a� 'Lot Size PM a y1 f Owner's Name i f�4 I n Q Phone C �v ror.,, Address . Contfactor i"04 64JLr Ca�Address r4'o+BC /'►�e License No. S4�+i3 v. Phone i87- W WELL REPLACEMENT N 0 DESTRUCTION TYPE OF WE1_L/PUMP: it NEW WELL r PUMP.INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER XOr Sail �r� . DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLU. ' PROP. LINE FOUNDATION AGRICULTURE WELL - OTHER WELL PITS/SUMPS ,I INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS R tE [1 lndustrlal ElOpen Bottom ❑ Manteca . Dia. ai Well Excavation Dia. of Well Casing �. {: (_1 Domestic/Private l- Gravel Pack 0 Tracy! Type of Casing N Specifications_ § !'1 Puhlic F1 Other :, fADelta" Depth.of Grout Seal Type of Grout 4�Lc d Trrn I I Irrigation �,��.,Approx. Depth I I Eastern Surface-Seal;Installed by Repair Work Done ❑ Type of Pump H P State Work bond " [ : r Well Destruction ❑ Well Diameter , 5eahng Material (top 5f]'1 I' Depth Filler Material (Below 501 -- I TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION 1+::DESTRUCTION f I (No septic system permitted if public sewer is available within 200 feet.) r Installation will serve: Residence .Commercial 1 Other 'i Number of living units: N Number of bedrooms jA Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK E7 TypelMfg `icapacity No.-Compartments � PKG. TREATMENT PLT. ❑-' it Method of Disposal i. f ' Distance to nearest: Well Foundation _ Property Lihe LEACHING LINE ❑ No. &Length of lines Total length/size FILTER BED D Distance to nearest: Well Foundation Property Line SEEPAGE PITS 1 1 Depth, Sine Number L1 Distance to nearest: Well Foundation Property Line SUMPS - .' DISPOSAL PONDS I hereby certify that I have prepared this application and dial the work will be,dona in accordance with San Joaquin county oidinances, stale laws, and li rules and regulations of the San Joaquin Local Health 133t'rict. Home owner or licensed agent's signature certifies the following: ":I certify that in the performance of the work'for which this permit is issued, I shall not employ any person in such manner as to become subject to;workman's compensation laws of California." Contractor's hiring or sub-contiacting signature certifies the following: "I certify thal'in the performance of the work for Which this permit is issued, I shall employ persons subject to workman's compensa . tion laws of California." '" r `� (0lVurtc Qa�t:r The applicant musk-calle H requi" inspections. Complete drawing on reverse side. I Signed X f j title; Date: —�^ - i OR DEPARTMENT USE ONLY O , Application Accepted by H bate + + Area � .. I l� Pit or Grout Inspection by Daterb 'Final.Inspection-by Date Additional Comments: t p © Stk 466-6781 ❑ Lodl ''369 3621 © Manteca. 823-7,104 ❑ Tracy 835-6386 Applicant - Return all copies to-.Environmental Health Permit/Services 1601 E Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT RE!M!+TEU. CK RECEIVED BY DATE PERMIT No. ' [INFO ,r CA5H ', . EH 13 24(REV.riKsi ICU . I fl. 1 W i