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APPLICATION,FOR PERMIT 4 . SAN JOAQUIN LOCAL HEALTH DISTRICT 1601.E.,HAZEL T ON 'AVE., STOCK-TON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1;YEAR FROM DATE ISSUED 4,(Complete]n Triplicate)-,C`-tlr r .r' Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. Thesapplication is made in-compliance-with San Joaquin County Ordinance No.':549 fors6vage or No..11862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. -41 `'] �. Job Address a[3��_ ,�._ � City� Lot Size � „ PM _Owner's Name -Address _ Contractor's Name 7� License No. (5,Y / r _ Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL_ PITS/SUMPS _ j INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS f ❑ Industrial 0 Open tottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ,❑ Public ❑ Other: L1 Delta' Depth of Grout Seal i Type of Grout f Y ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal ln1 tailed by I �✓ Repair Work Done 171 Type of Pump H.P. i State Work Done LV Work rWell Destruction ❑'i Well Diameter Sealing Material{p 501 (`. ` 4 Depth Filler Material(Below;w t3 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION ❑ (No septic system permitted if public sewer is r available within 200 feet.). ,,✓ Installation will serve: Residence Commercial— ther Number of living units: 1. Number of tLedroorrs Character of soil to a depth of 3 feet: 13V .�.� Ar- f Water table depth SEPTIC TANK ❑ Type/Mfg Capacity f ty No. Compartments PKG. TREATMENT PLT. ❑ 11 Method of Disposal. a ti Distance.to nearest: Well Foundation's Property Line LEACHING LINE e--No. & Length of lines .ri Total length/size r' FILTER BED .ir, `'❑ Distance to nearest:. Wall 3lLi� Foundation" Property Line �� a SEEPAGE PITS 11" .Depth Size J-6 Q �� i��Number-•-.--_ t { "SUMPS ° ❑ Distance to nearest: Well d U` Foundation r!t` Property Line- ' ` DISPOSAL PONDS ❑ t -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. -tet .-- r--s r- •.- TQM - :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 t employ any paison in such manner as tobecome subject to workman's compensatiomlaws of California." Contractors 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- Stion ia+nrs of California." �.--`".:,.tet �'•-��`s.�•.• _�. The applicant must call f I r quired inspections. Complete drawing on reverse side. , `Signed X Title: Date: L FOffi DEPARTMENT USE ONLY Application Accepted by Date Grout Inspection it Date �! � Final Inspection by + T Date Additional Comments: -E'❑ Stk -4664781.,' _ D Lodi-369-3621 - ❑ Manteca 623-7104 •❑ Trky',:835-6385';'" IApplica,4- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009,•Stk., CA 95201 FEE [± - -.•..�._-` ._ ,INFO. AMOUNT DUE `• AMOUNT REMITTED' . CASH{ RECEIVED BY DATE; PERMIT"N0. + EH 13.24(REV.10193) ..EH 14-28 I l