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APPLICATION FOR PERMIT v ti. SAN JOAQUIN LOCAL HEALTH DISTRICT 16131 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 r PERMIT EXPIRES 1,YEAR FROM DATE ISSUED j (Compiete in Triplicatei Application is hereby made to the San Joaquin Local Health District for 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 saws a oof�No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. t r y E 0-5'5— Job Address !erm i m Us City Lot Size PM ��+�a' S Address ( r piQ�lo `iy� �fo��ho Owner's Name ractor r �' E+E Address geebl i 0A 2f0License Noa�085'Lr?_7Phone I g" 0 Cort TYPE OF WELL;PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION El PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK none SEWER LINES L1012G DISPOSAL FLD.d�Z��PROP. LIN ` FOUNDATION hjQrle AGRICULTURE WELL 100trOTHER WELLJbnO PITS/SUMPS nQY1P1 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS- k ❑ Industrial C1 Open Bottom C] Manteca Dia. of Well Excavation Dia. of Well Casing 1 ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications /e—al 'V l'l Public /XOther I XDeita Depth of Grout Seaf Yype of Grout(cGJL!_k�r i I I Imi ation �.Approx. Depth I 1 Eastern Surface Seaf Installed by - r1 rl I State Work Done _ Ff$pai't Work Done Type of H.H P. Well Destruction ❑ Well Diameter Sealing Material (top 50.1 PentDni Depth Filler Material (Below 50'ih TYPE OF SEPTIC WORK: NEW INSTALLATION (.1 REPAIR/ADDITION I i DESTRUCTION I l INo septic system permitted if public sewer is Iavailable within 200 feet.) installation will serve: Residence + Commercial— Other Q Number of living units: Numbter of bedrooms 1" Character of sod-to a depth of 3-feet:I Water table depth SEPTIC TANK ❑ Type/Mfgi, Capacity No. Compartments PICC. TREATMENT PLT.❑ Y Method of Disposai _. _._.._..._ ._.. Distance!to nearest: — Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER ❑ Distance-to-neatest Wed,.—.-Foundation- Property Line SEEPAGE PITS _.... l 1 Depth I Size Number SUMPS 0 Distance�io nearest: Well Foundation Property Line DISPOSAL PONDS ❑ l hereby certify that i have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, slate laws; ands.� i' rules and regulations of the San Joaquin Local Health District. rk for which this permit is issued, I shall no Home owner or licensed agent's signature certifies the following: "I certify that in the-performance of the wot 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 ttie performance of the work for which this permit is issued,I shall employ persons subject to workman's compensa- tion laws 01C rnia." ,I - The applica st call fhr ail uir i ions. Complete drawingon r verse "da. Signed X l Title: k2aJJ Date: I FO DEP A ENT USE ONLY Application Accepted by 1r Date _ Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ Stk 466-6791 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 8:56385 Applicant- Return all copies to: Enviro.mental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 t F FEE AMOUNT DUE 1 AMOUNT REMITTEDCASH RECEIVED BY DATE PERMIT'NO. { INFO . EH 1321(REV.!1"sr '19.,De� r�� I EH 14-2d