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a APPLICATION FOR PERMIT I SAN JOAQUIN LOCAL HEALTH DISTRICT F x 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1-YEAR FROM DATE ISSUED (Complete in Triplicate) Application is.hereby made to the San Joaoaqul al Healt istftt r a permit to construct and/or install the work herein described. This application is made in compliance with San+��--o��uin Fqun Ord, or No. 1862 for welUpump and the Rules and Regulations of the San Joaquin Local Health District. }' L k Job Address / City Lot Size PM { Owner's Name Address ? Phone Contractor Address o - � License No3�lA Phone 9-19 i TYPE OF WELLlPUMP: NEW WELL LJWELL REPLACEMENT ❑ DESTRUCTION ❑ i PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑----r I DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL F-LR. - ~PROP. LINE FOUNDATION AGRICULTURE WELL Cl ELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA "CONSTRN SPECIFICATIONS v ❑ Industrial ❑ Open Bottom ❑ Manteca of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Grave! Pack ❑ Trac Type of Casing Specifications ("I Public ❑ Other elta Depth of Grout Seal Type of Grout k I I Irrigation *. —..Appro pth I I-Eastern Surface Seal installed by - t Repair Work Done' ElT Pump H.P. State Work Done Well Destruction '-- Well Diameter ; Staling Material Itop 541 --' 'Depth Finer Materia! (Below 501 C TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION LI DESTRUCTIO (No septic system permitted if public sewer is t r. available within 200 feet.) 1 Installation will serve: Residence_ Commercial— Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments E PKG. TREATMENT PLT. ❑ ' Method of'Disposal F Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines `+ Total length/size I FILTER BED ❑ Distance to nearest: Well • Foundation Property Line j SEEPAGE PITS- F) Depth Size - ' Number F 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, 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: "I certify that in the performance of theme work for which_this permit is issued,I shall employ persons subject to workman's compensa- tion laws of California." .The applicant ust call for all require inspe tions. Complete drawing on reverse side.• 1 `Signed -9. Title: Date: r k ale 1.FOR"DEPARTMENT USE ONLY 10Application Accepted by Date " Area ` .0 D Pit or Grout Inspection by Date Final Inspection by �G" K/�-�� _ Date Additional Comments: Z - - ❑ Stk 466-6781 ❑ Lodi :369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.Q. Box 2009, Stk., CA 95201 FEE MOUNT DUE MOUNT REMITTED t SFI RECEIVED BY DATE PERMIT NO. INFO . EH 13-241REV.1 nsl L EH 14-26