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4 _ Y APPLICATION FOR PERMIT i SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone {209} 466-6781 PERMIT EXPIRES 'I YEAR FROM DATE ISSUED (Complete in Triplicate) Application is heieby 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 Saq a - County 0 dinange No, fors wage or No. 1862 for welupump and the Rules and Regulations of the San Joaquin Local Health District. . LIR etp�p eel Job Address L 3 V4 City Lot Size PM Owner's Name Ltl aF Address �R Q� Phone �?' x ,, - 10 ? Contract W Address 1sl0r 17 v License No. $,�2� Phone TYPE OF WELL/PUMP:it NEW WELL ❑ WELL'REPLACEMENT ❑ DESTRUCTION ❑ 4, PUMP INSTALLATION ❑ �,SYSTEM,REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANKSEWER LINES � DISPOSAL FLD. - PROP. LINE FOUNDATION AGRICULTURE WELD � OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION-SPECIFICATIONS t ❑ Industrial ❑ Open Bottom C1Manteca Dia. of WV-Ii Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing /. Specifications M Public (7 Other ❑ Delta Depth of Grout Seal Type of Grout t I I Irrigation _._Approx.'Depth I i Eastern Surface Seal Installed by i T I Repair Work-Done"O'- Type of PumpH.P7 - - " -' --- 5fate Work Done— Well oneWell Destruction ❑ Well Diameter ,'.r' Sealing Materl Imp 50'i .Depth I"'.. wti ler'Material (Below 501 tJ _ r - I TYPE OF SEPTIC WORK: NEW INSTALLATION ['] REPAI /ADD TION- TDESTRUCTION I 1 INo•septic system permitted it public sewer is available within 200 feet.] Installation will serve: Residence— Commercial �/Othe^ Number of living units: Number of be ours, ! Character of soil to a depth of 3 feet: a Water table depth I SEPTIC TANK ❑ T e/Mf /, �. ` I YP 9 Capacity 1 < '�-%• i JNo. Compartments PKG. TREATMENT PLT. L1r" i ;' � � ' , , Method of Disposal 1 '' Distance to nearest: well Foundation Property Line r,,-f r ` fife { ` LEACHING LINE ❑ No. & Length of lines Total length/size ;/ e FILTER BED ❑ Distance to nearest: WellFoundation Property Line SEEPAGE PITS Depth s�_ ISize _ Number u " t I I Y SUMPS 0 Distance to nearest: WelLhTL_L, Foundation _- Property L'ine,_ S DISPOSAL PONDS ❑ i r I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquincounty ordinance`s, state laws, and rules and regulations of the San Joaquin Local Health District. At Home owner or licensed agent's signature certifies the following: "1 certify that in the performance of the work for.which'this permit is issued, I shall not employ any poison in such manner as to become subject to workman's compensation laws of California."Contractor's,hiring or sub-contracting signature I 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- , i tion laws of California." , The applican ust call f all equited inspections: Complete drawing on rverse Signed X Title' e rf r Date: FOR DEPARTMENT USE ONLY:., Application Accepted-by- ? ; Date- 4 h`$ or Grout Inspection by DateFinal Inspection by Date r7Q ry Additional Comments: �+ ❑ Stk 466-6781 ❑ Lodi 369-3621 C]"IUlanteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environme[al Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 ' FEEEAMOUNTT �J AMOUNT REMITTED RECEIVED BY CASH GDd']A14TE PERMIT'NO.O. EH 1324]REV:I/n sl EH 14-25 Aa� qU 6 C�qc �II m