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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466.6761 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Appeby ade made inion is compliance with Sanothe Joaquin nCounty ordinance uin No.549 for sewcal Health District for age permit to construct and/or install the work herein described This application is Local Health District. age or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin 23O (aI, c� Job Address '�r�IC / City t Lot Size P/M t7 Owner's Name _G, � D >< GOd1 Address _-2-2- 1 riy6f 7I /(/ P ✓ � 333 1704 ` Phone Contractorr/� `�!!(II/J$ ( _Address 373 60 TYPE OF WELL/PUMP: icense No. Pho NEW WELL WELL REP EMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ �N0N1`L,�� Wl l/ DISTANCE TO NEAREST: SEPTIC TANK OTHER Ih� / SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Ll Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation ElV Type of Casing Domestic/Private ❑ Gravel Pack ❑ Trac ! 5 h Dia. of Well Casing ng I� Specifications ElPublic ElOther ❑ Delta Depth of Grout Seal ry Type of GreetCli9P El Irrigation ---Approx. Depth El Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ElWell Diameter Sealing Material (top 50') 1,44. wl1( Depth n� — Filler Material (Below 50'1 TYPE OF SEP TIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ IN septic system permittedrf public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units:_ Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL 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 laws, and rules and regulations of the San Joaquin Local Health District. 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 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 the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applicanLkust call for all rr uire 'n io Complete drawing on reverse side. Signed X Z Title: Date: 9��/p4 f Date: FO EIR T BE ONLY Application Accepted b Date — Area �R J Pit or Grout Ins do Date/1�1 Final Inspection by zd Date 1113"d i Additional Commentq;. ❑ Stk 466-6781 0o 363 1 ❑ Manteca 823-7104 ❑ Tracy Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE NFO AMOUNT DUE AMOUNT REMITTED K RECEIVED BY LL DATE PERMIT NO. . ElRiiamlREv.riss' 35, coo ,x/17 86