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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT +( � 1601 E, HAZ.ELTON AVE., STOCKTON, CA 1)" Telephone 12091 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to the San Joaquin 1 oval Health Di:.Vt:t for a permie to corrSliuct and'or +r%Slall the work herein described This application is made in compliance vvith San.Ioaiwin Cauray Ordinance No 549 tot sewage or No 1862 for wire?pump and the Rules and Regulat+cins of the S:tn Joaaurn Local HeaRli Distract. Job Address Lot Sire PM �`5 dGte _ . ` � '' � 9oiQS 3j Phone Owner's Name _ dress - -- Contractor t[ .pQ��►a-rk4444" Address =3 q9D L�/L �.- License No. .— _____ Phone' � TYPE OF WfLL�'PUMP' NEW WELL WELL REPLACEMENT i DESTRUCTION PUMP INSTALLATION I' SYSTEM REPAIR : i OTHER (7 DISTANCE TO NEAREST: SEPTIC TANK — SEWER LINES _ DISPOSAI FID._— PROP. UNE .' FOUNDATION _ AGRICULTURE WELL ..—. 01HER WELL _ PITSSUMP5 INTENDED_ USE TWt bF WE1L r PROBLEM AREA CONSTRUCTION SPECIFICATIONS Ll IndustrialD Open Bottom 0 Manteca Dia of Well Excavation _ _. Dia. of Well Casing I Domestic/Privsl •� •C1 Gravel Pack C, Tracy Type of Casing. . — Specifications Public I1 Other 1`7 Delta Depth of Grout Seal _— Type of Grout -- _-- r , Irf.ljdlion ,a _ .Approx Depth I I Eastern Surface Seal Installed by -- Repair Work DWe 'f ' -Type of Pump _ ..__..._ _ H P _-- _ State Work Done i Well Destruction ' Well t�alneter Seal nq Material (lop 501 _ — • ' Oe�►1__ _.' _ Fii,ei Material (Below 501 - - TYPE Of SFPTW WORK. NE4*INSTALLATION Ri PAIll.ADDITION ' DESTRUCTION I I INo septic system ponn-Ired if puhl,c sewer Is n Joe dvdarab'e within 200 feet.) �l Installation will serve: Residence _ Commercial Other Number o1 living units: _— Number of bedrooms _ Character of soil to a depth of 3 feet: _ —__ _----- Water table depth SEPTIC TANK I 'I Typei Mfg _ Capacity _— No Compartments _ PKG TREATMENT PLT. 1 1 Method o1 Disposal — Distance to nearest: Well __ Founndat�ionn Property Line LEACHING LINE L t r .No. S Length of lines _— _� "'� Total length/size ' 1 41 r•ri r FILTER BED r Distance to nearest: Well _ __ Foundation /4 _ ___ Property Line .. SEEPAGE PITS I l Depth __---_Sire __- ___ Number SUMPS U Distance to nearest Weil Property Line DISPOSAL PONDS I-) 1 hereby certify that I have prepared [h$applicat.on and that the work well be dune in dr,coidance with Sari Joaquin county ordinances, state laws. and rules and regulations of the San Joaquin Local Health Di3tnct Home owner or licensed agent's signature certifies Ilio fogowmg "I Certify that in the performance of the work for which this permit is Issued, I shall not employ any parson in such manner as to become sublect to workman's compensation laws of California " Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work tot which this permit is issued. I shall employ persons subject to workman's comper" tion taws of California." l The apphcan st call (oral required inspections Complete drawing on reverse side. Signed X- `�T .� e' l��'� -- Title Date._ -__ F DEPARTMENT USE ONLY R Application Accepted by / _-_-_- _ __ Date Area Pit or Grout Inspection by —_- _ -- Date -__.-------------------- Final Inspection by Date *i"`— Additional Comments: / LI Stk 466-6781 L. Lodi 3693621 L Manteca 8237104 71 Tracy 835-MS Apphcenl - Return all copies to: Environmental Health Permit;Services 1601 E, Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED KT RECEIVED By DATE PERMIT NO INFO _ CASH . EH 13.24INEV i 71, i EH 14-26