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l y APPLICAI ION FOR PERMIT SAN JOAQUIN ''.� �CAL HEALTH DISTRICT 1601 E. HAZELT JN AVE., STOCKTON, CA ' 4Telephi a (209) 466-6781 PERMIT EXPIRES ' l YEAR FROM' DATE ISSUED (Coma 'ete in Triplicate) * } ;.. r I Application.is hereby made to the San Joaquin Local Health District I c r a Permit to construct and/or install the work herein described.This application is made in compliance with San Joaquin County Ordinance No.549 for. wage or No. 1862 for well/pump and.the Ryles and Regulations of the San Joaquin Local Health District. i Job Address } City `Lot Size AC, PM - Phone Owner's Names �E Address._ ' - x Contractor C- LU �` -1�[.L td License No.� Phone � 1 3 97/ + _ � Add_ress � + TYPE OF WELL/PUMP: NEW WELL [] t ELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ S SYSTEM REPAIR 1-1OTHEREl a DISTANCE TO NEAREST: SEPTIC TANK + r SEWER: I NES DISPOSAL FLD. PROP. LINE r i FOUNDATION IAGRICU TURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM ARE CONSTRUCTION SPECIFICATIONS y 1:1Industrial E] Open Bottom ❑ MantecaDia'of Well Excavation Dia. of Well Casing .4 e of Casin Specifications ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Typ g I.. Cl Public ❑ Other ❑ Delta I Depth of Grout Seal Type of Grout ❑ Irrigation _--Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. 4 State Work Done Well Destruction ❑ Well Diameter Seal) Material (top 50'1 ` i r Depth Filler•14aterial !Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION AIR!.A 6DITION (7DESTRUCTION .❑ (No septic system permitted if public sewer is e f i available within 200 feet.) Installation will serve: Residence_ Commercial— Otlrtr. Number of living units:_.�_— -Number�of bedrooms-3L i P I Character of soil to a de�pth�3 feet: I a I Water table depth _! 0 I SEPTIC TANK Ur Type/Mfg Capacity L 2:r No. Compartments I r k PKG. TREATMENT PLT. ❑ 4 Method of Disposal Distance to nearest: Well 1 Foundation j..— Property Line s LEACHING LINE No. 81 Length of lines Total length/size-'Z70 X Z ' FILTER BED ❑ Distance to nearest: Well Foundation r — Property tine SEEPAGE PITS Depth Size F' " / Number SUMPS ❑ .Distance to nearest: Well Foundation�� Property Line _ DISPOSAL PONDS ❑ ork will be done in accordance with San Joaquin county ordinances,state laws, and I hereby certify that ! have prepared this application and that th rules and regulations of the San Joaquin Local Health District. Home owner or licensed agent's signature certifies the following' 'I certify tthat in the performance of the work for which this permit is issued, I shalt not employ any person in such manner as to become subject to wor an s compensation laws of California."Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the w r for which this permit is issued,I shall employ persons subject to workman's compensa- tion laws of California." The applicant must call for all required inspectio Complete-d. ing on.reverseside. .� I Signed ` :1 itle: . Date: t\ FOR III EPARTMENT USE ONLY f CNi ,i Date. Area Application Accepted by ' `� ,fir r Pit r Grout Inspection by a –ISS Final'Inspection by Date_to:: Additional Comments: ❑ Stk 466'6781,X El Lodi 369-3621 12 Manteca -7104 El Tracy 635 6385 Applicant- Return all copies to: Environmental Health PeFmifl, ivices 1601 E. Hazelton Ave., P.Q. Box 2009, Stk., CA 95201 FEE 'AMOUNT DUE AMOl1NT REM! D CASH RECEIVED BY DATE PERMITNO. -ti ;INFO + EH 13-24(REV.1/8W EH 14-26