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r APPLICATION FOR PERMIT _ l , SAN JOAQUIN LOk CAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (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 or No. 1662 for well/pump and the Rules and Regulations of the San Joaquin made in compliance with San Joaquin County Ordinance No. 549 for sewage Local Health District. Job Address O W City Lot Size Z A_ PM 'r. Owner's Name Address Phone Contractor 1> WOW Address 7 Al, AD- 4— od4-8-7- License No.!yzx x'76.Phone AX- TYPE OF WELI_/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION C1I�SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC.TANK, SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS i INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing r ~_Specifications 0 El Domestic/Private ❑ Gravel Pack; ❑ Tracy iType of Casing I`1 Public l_l Other �_` /Cl Delta LDepth of Grout Seal Type of Grout Q `� ` 'm^ s' !Sufface Seal Installed by , "I1 Irrigation _..Approx.>Depth L I 1 Eastern r Repair Work Done 11 Type of Pump H-P. State Work Done 'Well Destruction ❑ Well Diameter f Sealing Material (top 50.1 l\ s Depth 'y _ Filler Material (Below 50'1- �� 'TYPE OF SEPTIC WORK: NEW INSTALLATIOM REPAIR7A_DDITION'T] DESTRUCTION I ]~iNo septic•system permitted-.4 public sewer is I available within 200 feet.) k �+r Installation will serve: Residence V Commercial_ Other !Number of living units: _/_.._ Number-of bedrooms- Z l • � Character of soil to a depth of 3 feet 4 1 S ^f A F Water table depth ` ,f SEPTIC TANK ❑ Type/Mfg ^-e- to ir-eL `F Capacity )ZB1 No. Compartments Z i PKG. TREATMENT PLT. El ` �'" r V Method of Disposal r Distance-to-nearest: well MO f=oundation Property Line �O LEACHING LINE }iK No. &Lerigth of lines 2 7B `- Total lengthlsize, i FILTER BED ❑ Distance to nearest' Well�%&44'If Foundation= -9 � Property Line ZS z I �y -C 3 —'Mi"r'a + SEEPAGE PUTS i�I Depth " 1 Size �� - '� Number SUMPS U1 Distance to nearest: Well ! Foundation' Property Line DISPOSAL PONDS ❑ r ''° �> 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. ,11 y that in the performance of the work for which this permit is issued, I shall not Home owner or licensed agent's signature certifies the following: "I certif employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature f t 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." ° f The applicant must call for all required inspections: Complete drawing on reverse side. I� Signed X . Title: C�!? Date: /-/,p'�p FOR°DEPARTMENT USE ONLY Application Accepted;by Date Area Pit or Grout Inspection by Date Final Inspection by Date / � Additional Cornments: ❑ 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..A36x 2009, Stk., CA 95201 FEE AMOUNT DUE+ AMOUNT REMITTED CK LAJSH RECEIVED BY DATE P E R M I T•NO'?fR.„ s. y INFO r.Eli 13-24 IpEV.r/w 51 EH 14-26 `�" -