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APPLICATION FOR PERMIT 4 � • SAN JOAQUIN LOCAL HEALTH DISTRICT Ti F 1601 E. HAZEL I ON AVE., STOCKTgN, CA N � � a Telephone (209) 466-6781 f PERMIT EXPIRES 1 YEAR FROM DATE ISSUED �d +L (Complete in Triplicate) Application is hereby made to-the San Joaquin Local-Health Oistrict for a permit to construct and/or install the work herein described. This application is 14 made in compliance with San Joaquin County Ordinance No. 9 for so eror No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District, s, i Job Address �� City "u'��1at Size PM O i ` Owner's Name 1! ul Address r Phone E Contractor (�S At#dress T� `e4-66,r License N Phone TYPE OF WELL/PUMP. i NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION i PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ i DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PUTS/SUMPS _ I INTENDED USE TYPE OF-WELL_ __.PROBLEM,AREA CONSTRUCTION.SPECIFICATIONS i C1Industrial 71Open Bottom 11Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications — k 1-1 Public Cl Other ❑ Delta Depth of Grout Seal Type of Grout f I I Irrigation —.Approx. Depth I I Eastern Surface Seal Installed by _ ki Repair Work Done 0 Type of Pump H.P, State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Fillet Material (Below 501 I TYPE 4F SEPTIC WORK: NEW INSTALLATION I:] REPAIR/AODiTION ['I DESTRUCTION (No,septic system permitted if public sewer is ' vailable within 200 feet.I if Installation will serve: Residence Commercial— Other Number of living units: Number of bedrooms �f kCharacter of soil to a depth.of 3 feet: f Water table depth SEPTIC TANK ❑ 'Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line r-yu LEACHING LINE 0 No. & Length of lines � �� Total length/size FILTER BED ❑ Distance to nearest: "Weill Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS Ll 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:_'.'(certify that in-the performance-of-the:work for which this permit is issued, I 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: '9 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 t st cal for all.required ins ctigns. Complete drawing on verse side. I Signed Date: *+� TEPARTMENT USE ONLY �') Application Accepted byADate �i dArea L Pit or Grout Inspection by Date Final Inspection by Date 'i Additional Comments: �G .L '�W/fi l lll�9� ��? � "^ 7 1xliLlz ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 1� Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 9FEE5201 J1 INFO AMOUNT DUE AMOUNT REMITTED CK 49 ASH RECEIVED BY DATE PERMIT'NO. ♦ EH 13-241 REV.i i H 5) /� EH 14-28V iV� .� l�Wf!'' I ~Il/ �/ 7 0 J.