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k APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE.,.STOCKTON, CA 4 Telephone f 2091 466-091 PERMIT EXPIRES YEAR} 1 FROM DATE ISSUED : .s {Complete in Triplicate} �•. :, v +. . , 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 of No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. - Joh AddressT City of Size pM: F4 Owner's Name �fnry res /� MPhone tor ac - Address � License No. �Ph4oi ��d' � TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ ' I DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL r 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 �� F1 Public O Other Ll Delta Depth of Grout Seal Type of Grout ❑ Irrigation ---Approx. Depth C] Eastern Surface Seal Instailed_by- Repair Work Done ❑ Type of Pump H.P. State Work Dorie-l"� ! Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') --..- __ ► i TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ .-REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public_sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Otherg^ , -8 .�- Number of living units: Number of bedrooms i Character of soil to a depth of3 feet''., Water table depthy : SEPTIC TANK ❑ Type/Mfg :' Capacity No: Compartments �- w PKG. TREATMENT PLT. ❑ i Method of Disposal `"'Distance to nearest: Well Foundation ; Property Line LEACHING LINE No & Length of lines length/size FILTER BED �)D Distance to nearest: Well Foundation_.•Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS r ❑ Distance to nearest: Well Foundation , Property Line ' Y DISPOSAL PONDS ❑. J 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 Cania." speY -.,..�. The applicant mu calif req red i ctions.ion to drawing on reverse side. oziSigned Title Date } FOR DEPARTMENT USE ONLY Application Accepted by e Area - Pit or Grout Inspection by bate Final Inspection by Date E ; - Additional Comments: ❑ Stk 466-6761 , IXLodi 369-3621 El Manteca, 823-7104 -E] Tracy. 835-6385 all c Applicant-Return apias-to: Environmental Health'Permit/Services 1601 E. Hazeiton Ave., P.O. Box 2009;Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT`NO. � EH13-241REV,1/n5) 7]A L cam. 7nfT,, Je1�i EH 1428 !LJ. Q 37J•� r.'C/ g_ Zrs