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APPLICATION FOR PERMIT "^ t G--� SAN JOAQUIN LOCAL HEALTH DISTRICT * � §'� Y f 1601 E. HAZE T ON AVE., STOCKTON, CA4 '' Telephone (209).466-6781 PERMIT EXPIRES T YEAR FROM DATE ISSUED Qa ft-Ga VAPO (Complete in Triplicate) 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.5W ge or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin j Local Health Di;tjic� ^^'dr ,,,,,,�p� ��3 /" "" J '/d�j' /'�^.' nr'�_" Ci Lo Size ^�M job �Addressl Owner's Name ress Phon / Contractor dress�V �L�'/_ `�"/ 1/'�License N �Phon TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION X SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK. SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of;Casing Specifications ,1�w 1'7 Public ❑ Other ❑Delta Depth of Grout Seal Type of Grout-, irrigation —.-Approx. D I Eastern S rface Seal Installed by - t Re-pair Work Done ❑ Type of Pump re�� H.P. State" k Done Well Destruction ❑ Well Diameter - + Sealing Material (top 50') Depth Filler Material (Below 50') • TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION LI DESTRUCTION l I O%e' r is avai Installation will serve: Residence_ Commercial_ Other �Q 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 f I Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I I K I 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 Di§trct. Horne 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 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 compensa- tion laws of California." The applica ust call or all required inspe ions. Complete drawing on reverse sloe. Signeda&YA Title: /LDate: F, DEPARTMENT USE ONLY Application Accepted by Date `— Area Pit or Grout Inspection by Date Final Inspection b � �_ Datl-i-I _1 1 Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ 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 FEE AMOUNT DUE AMOUNT REMI ED CK RECEIVED BY DATE PERMIT'NO. INFO CASH EH +.EH13-241REV.1i85) �� EH 1448