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Ole - APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT ,.; 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 Joaquin Local Health-District for a permit to construct and/or install the work herein described. This application is Local Health District. pump and the Rules and Re made compliance with San Joaquin County Ordinance No. 549 for-sewage or No. 1862 for well/ gulations of the San Joaquin as r f Job-Address LLLL f City Lot Size PM Owner's Name / Address l f f. - Phone Contractor J Address TYPE QF WELL/PU P_ License No Phone „-. _NEW WELL_p x .. WELL REPLACEMENT ❑ PUMP INSTALLATION ❑ 1]ESTRUCTION ❑ SYSTEM REPAIR ❑ DISTANCE TO NEAREST: SEPTIC TANK OTHER ❑ \ � SEWER LINES DISPOSAL FLD: ` FOUNDATION rAtGRICULTURE WELL_ Y PROP. LINE` OTHER WELL PITS/SUMPS 1 INTENDED USE TYPE.OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS } ❑ Industrial D Open Bottom �— ❑ Manteca Dia. Of Well Excavation L1 El ElGravel Pack- Dia. of Wel! Casing C7 Tracy Type of Casing ` F'f Public n Other - T -- -.- Specifications �. *- .n Delta Depth of Grout Seat t ! I Irrigation —.Approx. Depth' I i Eastern Type of Grout Repair Work Done Q T -Surface Seal Installed by f Type of Pump - H.P. _ Well Destruction ❑ Well Diameter State Work Done_ .+� 7-_ Sealing Material (top 50') `�� Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTAL ATION ! REPAIR/ADDITION�i.I DESTRUCTION i I jNo septic system permitted if public sewer is k I Installation will serve: Re idence ftt available within 200 feet.) Commercial mer------- Number � i Number of living units: Number o edroom ^^ Character of soil to a depth of 3 feet: � �* SEPTIC TANK ❑ Type/Mfg Capacity� Water table depth �� PKG. TREATMENT PLT. ❑ . y --s` No. Compartments Method of Disposal ; Distance to nearest: -, Well Foundation Property Line 1 LEACHING LINE No.,& Length of lines FILTER BED ❑ Distance to nearest: ell � Total length/size Foundation 7r`0—= Property-Line SEEPAGE PITS -- - -'- fro `GL I I Depth i Z9 � � • UMP n Number fro Cl Distance to nearest: well Foundation Property Line — *.$ 4=p ISPOSAL 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 Eaws, and rules and regulations a the San Joaquin Local Health District. Home owner or licensed agent's signature certifies the followin � employ an _ g: "I certify that in the performance of the work for which this Permit is issued, I shall not I P Y Y person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub contracting signiure... certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall em to tion laws of-California." P P y persons subject to workman's,compensa The applicant ust all fo all req"inspections. ate drawing on reverse side. Signed X Title: r s Z__ Date: FOR DEPARTMENT USE ONLY - .n Application Accepted by Date Area Pit or Grout Inspection by bate —�� Final Inspection by Date Additional Comments: t x�� ❑ Stk 466-6781 ❑ Lodi 369-3621 �^� _ ��aYr-0Vh, Applicant- Return all copies to: Environmental Health*Peermit/Sere ces41601 E0 Tracy 83-6385 P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CK RECEIVED B ASH ` Y DATE PERMIT•NO. �] 4 � EH 13-24IREV.FC ins1 // /{��AQ t EH 14-28 v •V U U C J