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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA aE Telephone (209) 466-6781 PERMIT EXPIRES 1'YEAR FROM DATE ISSUED ' (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to c made onstruct and/or install the work herein described. This application is Local Health Distri��s.�,3, well/pump compliance with San Joaquin County Ordinance No,549 for sewage or No. 1862 for and the Rules and Regulations of the San Joaquin � k Job Address <:AE7 ►� , City of Size PM I Owner's Name _ Address hone Contractor Address Gtr>ze� I License No. TYPE OF WELLlPUMP; W WEL, �,., _ 4w"ICL��7 Phone �"+ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION f SYSTEM REPAIR ❑ DISTANCE TO NEAREST: SEPTIC TANK OTHER ❑ I 1 SEWER LINES DISPOSAL FLD-!! r FOUNDATION PROP, LINE AGRICULTURE WELL --- OTHER WELL PITS/SUMPS ! INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATION ❑ Industrial Q Open Bottom ❑ Manteca Dia. of Well Excavation omestic/Private }Gravel Pack F) Trac f Dia. of Well Casing fo ' r t-1 Public y / Type of Casing Other C1 Delta r Specifications ! I Ifrigation 72J� Depth of Grout Seal �Approx, Depth I 1 EasternTYPe of Grout Repair Work Done 0 T Surface Seal Installed by ", -- Type —� Well Destruction ❑ Welll Diameter State Work Done Sealing Material (top 50') Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW 1NSTALIATION i'l REPAIR/ADDITION I ! DESTRUCTION E I'(No septic system Commercial� Other permitted if public sewer is t Installation will serve: Residence available within 200 feet.) Q Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: SEPTIC TANK ❑ Type/Mfg Water table depth ' Capacity_ _No.TREATMENT.PLT. ❑" - ` r -�- _No. Compnosalq' i ..r_ Method o Distance to--nearest: Well- - ---•-Foundation"• - Pfoperty Line LEACHING LINE Ll No. & Length of linesFILTER BED ❑ Distance to nearest: Well Total length/sizeFoundation Property LineSEEPAGE PITS I 1 DepthSUMPS SizeNumberJ L1 Distance to nearest: Well DISPOSAL PONDS ❑ Foundation Property Line hereby certify that I have prepared this application and that the work will be done in accordance with-San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health Di§trict. Home owner or licensedagent's signature certifies the following: "1 certify that in the perfo/mance of the work for which this permit is issued, i shall.not employ any person in such manner as to became subject to workman's compensation laws'of California."Contractor's hiring or sub-contracting signature certifies the followin g: "I certify that 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." The applicant SII equir ons. Complete drawing on revpe side. Signed X .Zyy .. - Title: p _:s-moi Date: tl FOR DEPARTMENT USE ONLY h Application ccepted by e *' Date Area N Pit or rout spection b ' �✓J//J�//e Date�Y Final Inspection by Date /_i k Additional Comments: Stk- 466-6781 ❑ L•odi 369-3621 -- I„t q' ❑ Manteca 823-7104 q Tracy 835-6,385 �• Applicant - Return all_copies-to: Environmental Health'Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, $tk., CA 95201 S 9,. t?S. -FEE ( INFO AMOUNT DUE ; F �AMOUNT.REMITTED CK 1 CASH RECEIVED BY t; : DATE +.EH 13-24 IRfV,t i H s) PERMIT'NO.