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¢ _ APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA w -Telephone 12091.466-67$1 # :PERMIT EXPIRES 1 YEAR FROM DATE ISSUED A (Complete in Triplicate) _ Application is hereby made to the San Joaquin Local Health District permit e ur INo. 1862 for wellldpump and the Rules and Regulall the we described of the 5anf Joaquin made in compliance with San Joaquin County Ordinance No:549 sewage Local Health District. ' y,� rerl City""&,V& Lot Size PM 1® Job Address � r. Phone r V6 ,4ddress t pwner`s Name Phone Contractor cess" WELL REPLACEMENT ❑ DESTRUCTION`0 ; TYPE OF WELL NEW wELI `❑ OTHER''Q d f e tSYSTEM REPAIR [1`.1UMP INSTALLA+ ION ❑ ; DISPOSAL FLD. = PROP. LINE DISTANCE TO NEAREST: SEPTIC TANK_;may SEWER LINES FOUNDATION� •? ' ' AGRICULTURE WELL OTHER WELL "PIT:SISUMPS ' 1 •. PROBLEM AREA CONSTRUCTION SPECIFICATIONS INTENDED USE TYPE OF Ea-- �--- Dia. of Well Casing ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Weil Excavation , r. g Type of Casing Specifications t ❑ Domestic/Private ❑ Gravel Pack* ❑ Tracy yp Type WGrout f° ❑ Other d j 11 Delta Depth of Grout Seal 3 11 Public ' 13 Irrigation �,4pprox. Depth ❑ Eastern Surface Seal Installed by s s H.P. State Work Done— j Repair Work Done .1❑ Type of Pump Sealing Material (top 501 F Well Destruction r❑ Well Diameter"�, Deptfi `' per Material (Below 50'i } ' tic system permitted;if public sewer is available,within 200 feet.) TYPE OF SEPTIC WORK: NEW INSTALLATION -1 REPAIR/ADDITION ❑ QESTRUCTION ❑ INo-sep ' Installation,viii serve: Residence :Commercial_ Other t � ,�_ s. 1.. ` if Number of bedrooms $' Number of living units: i� Water table depth [ Charact8r"of soil to a depth of 3 feet:,. Capacity Zl/0— t Compartments SEPTIC TANK ❑ Type/Mfg Method of Disposal : +v PKG. TREATMENT PLT. ❑ c F hdation_l2 Property Line'_ 'Distance to Well_F?"y�� L 2 Total length size LEACHING LINE ❑ No. & Length of lines Foundation v roPertY Line FILTER BED C1 Distance to nearest: Well Number t SEEPAGE PITS ❑ Depth ± Size— �. Foundatiom�-- Property Line SUMPS ❑ Distance to nearest: Well ; I . I DISPOSAL PONDS ❑ f { %Ya 1 hereby certify that I have prepared this:application'and that the work will be done in accordance.with San Joaquin unty ord'+nances, state laws, and" l not rules and regulations of the San Joaquin Local Health District. j .. Home owner or licensed agent's signature certifies the following:rkman'srcompensat on"I lwsoof_Californ a:ance of e Contractor's work for olhir ng1 oP sub cont acermit is t nglsignature: . employ any person in such manner as to become subject to arsons subject to workman's compensa-' f certrfies the following:"I certify that in the'performance of the work for which this permit is issued,I shall employ p t tion laws of California." The applicant ust call for-al required inspections."ComPl#to drawing on reverse side. J Date: ! r ' Title: � Signed '� 1 FOR DEPARTMENT USE ONLY [ a ,,�5Area {J Date A ation Accepted by t { 9 ate 'S f incl Inspection by Pit o Grout Inspection bjr Additional Comments: ❑ Stk 466-6781 ❑ odi 3693621 ❑ th eco Ser 71 ❑ Tracy 83rB385 /�� II copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA�5201 Applicant - Return a p I i CK# 'RECEIVED BY DATE PERMIT''NO. FEE AMOUNT DUE AMOUNT REMIT FED CASH INFO r + EH 13-24(REV.1/B 5) Eli 14-28 ... - .