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a APPLICATION FOR PERMIT „ SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZETON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED { (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work herein described. This application is wage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin made in compliance with San Joaquin County Ordinance No.549 for se Local Health District. Job Address l� City Size PM Owner's Name GL-s- '�` .� ✓�/� Address �j"'� Phone Contractor �'v 0 H � II License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ _DESTRUCTION ❑ PUMP INSTALLATION ❑ i5 SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA 'sCONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy +iType of Casing Specifications fl Public ❑ Other C) Delta' I,Depth of Grout Seal Type of Grout — I iIrrigation —._Approx.,Depth� 'I'I-Eastern, surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. 'I State Work Done _ Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth �� Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION l l REPAIR/ADDITION I I DESTRUCTION VNo septic system permitted if public sewer is available within 200 feet.) installation will serve: Residence_ Commercial_" Other I' Number of living units:/ Number of bedrooms Character of soil to Aepth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg ' Capacity ' No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well �, Foundation Property Line LEACHING'LANE ❑ No. & Length of lines. �! Total length/size FILTER BED ❑ Distance to nearest: Well I Foundation Property Line SEEPArGE PITS I I Depth Size 9L Number l SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I 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 District. Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, 1 shall not employ any person in such manner as to become subject 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 for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applica st calk for all req uir inspection plate drawing on reverse side. Signed X Title: Date: a f FOR DEPARTMENT USE ONLY i by Date Application Accepted 4 Area Pit or Grout Inspec' n DDatce f=inal inspection/ by �7 Date Additional.Comments:; ❑ Stk 466-6781 - . © Lodi 369-3621 El Manteca 823-71 04 �✓❑ Tracy 635-6385 Applicant - Return all copies to: Environments! Health Permit/Services 1601.E. Hazelton Ave., P.O. Box 2009,"Stk., CA 95201 FEE 7 AMOUNT DUE AMOUNT REMITTED i CK � RECEIVED BY DATE PERMIT'NO. INFO CASE{ r EH 13-24(REV.1/"5) i++ ' S-7 EH 14-26 ^' I? 'f