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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT �� 1601 E. HAZEL i ON AVE., STOCKTON, CA Telephone (209) 466-6781 112 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED APR 9 kvSD (Complete in Triplicate) ENVIRONMENTAL� HEALTH ( Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the wo[nx� ef6tn e�c?r e Ii Gcation is f made in compliance with San oa uin County Ordinance No. 9 for sewage or No. 1862 for welU pump and the Rules and Regulations of the San Joaquin Local Health District. t Job AddresLam. mit . of Size PM shone Owner's Name l Addres W 03 14"se No! Phone Contra a I TYPE OF WELL/PUMP: NEW WELL fl WELL REPLACEME ❑ w. DESTRUCTION ❑ PUMP INSTAL"L4TION� SYSTEM REPAIR ❑ OTHER ❑ _ DISTANCE TO.NEAREST: SEPTIC.TANK_� SEWER LINES � DISPOSAL FLD. .PROP. LINE FOUNDATION '- _ AGRICULTURE WELL OTHER WELL PITS/SUMPS = � INTENDED USE TYPE OF WELL - PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing fl industrial ❑ Open Bottom El Manteca Dia. of Well Excavation Type of Casin Specifications K7 t ED Domestic/Private - Cl Gravel Pack ❑ Tracy yp g Type of Grout - F] Public 1-} Other ❑ Delta Depth of Grout Seal I I Irrigation —..Approx. De th I astern Surface Seal installed by f` H p State Work Done Repair Work bone 'LD Type of Pum r j Well Destruction 'D Well Diamet'er Sealing Material (top 501 - fk Depth r. Filler Material (Below 501 - TYPE OE.,SEPTIC WORK: NEW INSTALLATION I i REPAIR/ADDITION I DESTRUCTION I I availabBtic system feetrtted if public sewer is Installation will serve: Residence— Commercial_ Other - Number of living units: Number of bedrooms z Water table depth Character of soil to a depth of 3 feet: SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments + PKG. TREATMENT PLT. ❑ Method of Disposal t - �r-^�*+�^ Distance to nearest: Well Foundation Property Line `- f LEACHING LINE` ❑ ',No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line f SEEPAGE PITS l I Depth Size Number } SUMPS L1 Distance to nearest: Well Foundation Property Line DISPOSAL-PONDS � ❑., ._. _ �------ -. _- _ __: __�- �-��..�_-��...--�--�� -� - •,.� I ( and that the work will be done in accordance with San Joaquin county ordinances, state laws, and I hereby certify that VWave prepared this application rules and regulations of'the San Joaquin Local Health District. Home owner or licensed adent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, l shall not employ any person in sudin manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature - E 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 R tion laws of Calif6inia." The applica st,callor r d inspection's. Complete drawing on re se side. Titia: Date: Sig d X , FOR DEPARTMENT USE ONLY l Date Area Application Accepted by Pit or Grout Inspection by Date Final inspection by Date 3 Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 623-7194 ❑ Tracy 835-63$5 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.Q. Box 2009, Stk., CA 95201 j 1F FEE AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED 9Y DATE PERMIT"NO. �'��//� ♦,EH43-24IHEV.tin51INFO 1l� �� EH 1426