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• APPLICATION FOR PERMIT I SAN JOAQUIN:-LOCAL HEALTH DISTRICT { 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 I PERMIT EXPIRES 1 YEAR FROM DATE ISSUED u ;;,„ ,.;4, .• (Complete in Triplicate) -7#! a3-7 O I 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 made in compliance with San Joaquin County Ordinance No.549"for sewage or No. 1862 for well and the Rules and Regulations of the San Joaquin p Local Health District. - tl :.�.,.,,• , 775 GrJ, �."�'�p�/�ir' ��y' Job Address City rCt Lo#Size 175 X 6 PM '•' Owner's Name _�11�t�� Address .r -" - F �a Phone 931ce 99X949 Contractor Address.352a* TYPE OF WELL/PUMP: NEW WELL ' License No. 1 9)X/3 Phone WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINESk DISPOSAL FLD. .'4 PROP. LINE o� FOUNDATION I AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL r I PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom i❑ Manteca Dia'of Well Excavation r' 1Z Domestic/private Dia. of Well Casing Gravel Pack w l9 Trac "`'4 i.., e ' Y Type of Casing_ j/ ❑ Public 1:1 Other �:" J. Specifications �" ❑ Delta Depth of Grout Seal ❑ Irrigation Type of rout ---Approx. Depth ❑ Eastern Surface Seal installed by — C61iZ19_,4 Repair Work Done ❑ Type of Pump H".p. Well Destruction ❑ Well Diameter State Work Done i R Sealing Material (top 501) ff Depth Filler Material (Below 50') I OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system`permitted ifpublic sewer is Installation wi Residence— Commercial Other available within-200 feet.) Number of living units: "Number of bedrooms { Character of soil to a depth of 3 fe ` S f SEPTIC TANK Water table depth i ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ 6 v Method of Disposal Distance to.nearest: Wellundation 1 Property Line 4 ji- LEACHING LINE ❑ No. & Length of lines ' ' ; ii- 1 length/size FILTER BED ❑ Distance to,neamst: Well Foundations s Line SEEPAGE PITS ❑ Depth Size SUMPS Number \ 1 ❑ Distance to nearest: Well Foundation " DISPOSAL PONDS ❑ ( , 1 `' Property Line- hereby certify that I have prepared this application aq)d that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Healih 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,1 shall employ persons subject to workman's tion laws of California." compensa- tion R The applicant ust call for all required inspections. Complete drawing on reverse side, _ r Title: Signed Date: I FOR DEPARTMENT USE ONLY Application Accepted by �Q r/�f Date " _a ":p Area lef Fi Pit or Grout Inspection by 1$at nal Inspection by Date , Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-36.11 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return ail copies to: Environmental Health Permit/Servicas 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 9520 µ _ 1 1y FEE AMOUNT DUE AMOUNT REM(TTEp INFO CAn RECEIVED BY DATE PERMIIT''NO. + EH 1 -241REV.r/s5) EH 1426 4 _ � .1-7,,91