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APPLICATION FOR PERMIT a . SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE.,.STOCKTON, GA Telephone (209 466-6781 , PERMIT EXPIRED YEAR FROM DATE ISSUED . (complete in3riplicate) 'y application is rm r No. 1862 for well pump and the Pe No, to construct andlor install the work herein described.Rules and Regulations of tf t e app Application is hereby made to the San Joaquin Local Health District for a p aquin County Ordinance No.549 for sewage or. he San Joaquin # made in compliance with San Jo_ a - -• _ . s r Local Health Districts q: t J }' NlUL City �� Lot Size PM > Job Address �; , r _ .. Phone j Address ` Owner's Name Phone License NO. Address Contractor L' " DESTRUCTION ❑ NEW WELL WELL REPLACEMENT ❑ OTHER ❑ i TYPE OF WELLlPUMP: SYSTEM REPAIR ❑ PROP'. LINE i PUMP INSTALLATION ❑ DISPOSAL FLD.— ", SEWER LINES �� OTHER WELL P17SISUMPS DISTANCE TO NEAREST: SEPTIC TANK AGRICULTURE WELL �— i FOUNDATION PROBLEM ARE • CONSTRUCTION SPECIFICATIONS INTENDED USE TYPE OF WELL Dia. of Well Casing ❑ Manteca Dia. of Well Excavation , r ❑ Open Bottom _�� Specifications--�--- ❑ industrial T_ype.of_Casing } ❑ Gravel_Pack„� Q_Tracy rte-- Type of Grout C_)`DomestictPrivate _�-- ❑ Delta Depth of Grout Seal i'' ` ❑ Public ❑ Other Surface Seal Installed by ' •,;* :; _--Approx. Depth ❑ Eastern State Work Done ❑ Irrigation r� H.P.Type o � - Repair Work Done ❑ ypf Pump Sealing Material (top 50') .* Well Destruction ❑ Well Diameter Filler Material (Below 50'1 r' is ; i I REPAIRlADDITI01�l1 DESTRUCTIDIV ❑ Savailabpe whin 200 f--feet.) if public sewer is NEW INSTALLATION• = 1< €; TYPE OF SEPTIC : ORK: ; y ( C Others ar7 G Installation will srve: Residence Commercial �Jv . ; I !Number of �dro — '�' --' '�" Water table depth Number of living 1unrts: G Character of soil a depth of 3 feet: r` f ' p� No{GomQartments x Cap "city ` SEPTIC TANK t. ❑ Type/Mfg _` 1 Method of Disposal , r �,�^ PKG. TREATNIENTJPLT. ❑ Foundation Property Line - 4 Distance to nearest: /Vllel�l l 1W.,Of s Total lengthlilze 6 LEACHING LINE x: �a. & Lengfil.Of line �` }.. ! Foundations Property amine FILTER BED' L7, -Distance to nearest: i' tjr„ - Number ; Y I 0 Depth z lze Line SEEPAGE PITS dat ons —""'" Property SUMPS '. � 4 _Distance to nearest:----.Well ,rJ—Foundation, --'.'""Founr i 1 �i DISPOSAL PONDS' ❑ an Joaquin county ordinances, state laws, and r hcation and that the VuOt Will a-done in a cardance with ;; { x I hereby certify that I have prepared this app rules and regulations of the San Joaquin Local Health fo-District. io i following: t to workman's-compensation-laws_of-California.'=Contracteo nsrsubject to workmanlscompensa- Home owner or lice�rsed agent's signature certifies tbollowin I certify that in the performance of th work for which this permit is issued, I signature shall no r employ any person in such manner as to become su I certifies the foHowirig: "I certify that''in i he performance of the work for which this permit r issued, I she p Y tion laws of California." fi ? t •; /— The applicant must call for all require d 'nspections. Complete drawing on reverse si e. i pater �' /'a• Title: Signed 1 g FOR DEPARTMENT USE ONLY 9 � l Date ; Area Application Accepted by - I �;; Date Final Inspecrtion by Pit or Grout Inspection by Date Additional Comments: 7104 acy 835 5 ; ❑ Manteca Stk_, CA 95201 ❑ Stk 466.6781 i ❑ Lodi 369 362 ( Applicant- Return II copies to: Environmental Heyalth PermitlServices.1601 E. HYD�t° ` P•O 4 CKDATE PERMIT NO: J FEE AMOUNT DUE AMOUNT.REMITTED CASH RECElV6D BY INFO (-� fi5�aaS ^£.� ., 1 + EN 13-24:(RE1l.I/ - i ER 14-26' - - • - - - -.