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APPLICATION FOR PERMIT / SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA ' Telephone (209) 466-6781 - V 1 L r PERMIT EXPIRES 1 YEAR FROM DATE ISSUED {Complete in Triplicate} , p 0S,_ 29o ^�� Application is hereby made to the San iJoaquin Local Health District for a permit to construct and/or install the work herein described. This application is made in compliance with San aquin C ty Ordinance Na.�549fwage or o.1862 forrwell/pump and the R les and Re t' f th S J quirt'Local Health District. � � 74 ,41 )f /r, r' _!Job Address _?/ .Ci+y iizzem� '��c�PM ll �J' Owner's Name ,i Contractor's Name �� nse No. +� Phon f o[ t TYPE OF WELL/PUMP: NEW WELL 9�� WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION Dl" SYSTEM REPAIR ❑ OTHER Cl I DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION 7 AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS . T ❑ Industrial en Bottom ❑ Manteca Dia. of Well Excavatio Dia. of Well Casing er mestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing f Specifications El Public ❑ Other , ❑ Delta Depth of Grout Sea! Type of t ❑ Irrigation _.Approx. Depth ❑ Eastern Surface Seal Installed by r Repair Work Done ❑ Type of Pump , ,:.tea H.P. 57 State Work Done Wel! Destruction ❑ Well Diameter Sealing Material (top 50') Depth `�� Filler Material (Below 50'► TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is 5 available within 200 feet.) �I Installation will serve: Residence_ Commercial_ Other M Number of living units: / Number of bedrooms C Character of soil to a depth of 3 feet: Water table depth } SEPTIC TANK ❑ Type/-f4fg Capacity No. Compartments L PKG. TREATMENT PLT. ❑ ilk Method of Disposai r i.fistance to nearest: Well Foundation Property Line ` LEACHING LINE ❑� No. & Length of lines Total length/size Q FILTER BED ' SCJ Distanceito nearest: Well Foundation Property Line I SEEPAGE PITS r0 Depth 1 Size Number r SUMPS X❑ Distance to nearest: Well Foundation Property Line r DISPOSAL PONDS .T,❑ I hereby certify that,l 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."Contractors hiring or sub-contracting signature ` certifies the follow!Kg:;Icertify 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 applicant mus call for II required inspections. Co plat ing on reverse side. Signed '� �- � Title: _ Date: / FOR DE RTMENT USE ONLY Application Accepted by Date F" -3— Q Area Pit Or Gro_ } spection by Date Date Final Inspection by Date i Additionail'Comments: c ❑ Stk 466.6781 OLodi . .369-3621 F-1 Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all-copies to--Environmental Health Permit/Services 1601,E."Hazelton Ave., .P_.O._Box 2009, Stk., CA 95201 INFO AMOUNT DUE AMOUNT REMITTEDCK RECEIVED BY DATE. PERMIT`NO. +Er+ ffir 241REV.10! $ 7 ! W EH 1428'"'"