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APPLICATION FOR PERMIT V e, •�r_ SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL I ON AVE.,J STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 11YEAR FROM DATE ISSUED {Complete in Triplicate)iv Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein descnbed..Thts application is i made in compliance with San oaquln aunty Ordin nce No.549 for se a or No. 1862 for well/pump and the Ryles and Regulations of the San Joaquin Local Health"District. �' fw s '�C(.<; �(-�- ' r"J ') 4v�:krf �-G V 1 w 4 Z +S' } t Job Address .b Ci .t Lot $1Ze PM , - Owner's Name Address P one Contrac Address -7-A2: l"Al � lz_License N Phone TYPE F WE /PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial Open Bottom 0 Manteca Dia. of Well Excavation Dia. of Well Casing Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout Irrigation ---Approx.lDepth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction Well Diameter Sealing Material stop 501 Depth Filler Material {Below 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑- DESTRUCTION ❑ iNo septic system permitted if public sewer. is (}� y available within 200 feet.) �(1 Installation will serve: Residence 3 Commercial_ Other CN Number of living units: Number of bedrooms a II'ti Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ 1 ! 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 ❑ Depth Size Number SUMPS F1 Distance rto nearest: 'Well Foundation Property Line „ DISPOSAL PONDS 171. I hereby certify that I have prepared this application arid'that the work will be done in accordance with San Joaquin countyordinances, state laws, and rules and regulations of the San Joaquin,Local Healtfi Dis{rict. 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 i 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 campensa i tion laws of California." r l I -The applica ust call for all e I d ins ction mplete drawing on reverse side. i vied L� iGl 1p=e�,�/ .. Title: , _ . Date: —2,0— S g ;` t; -j FOH DEPARTMENT"ll$_F ONL`lr`"" F by Date Application Accepted Area �£ Pit or Grout Inspection by Date Final Inspection b R y Date +' Additional Comments: ": l ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Servioes 1601 E. Hazelton Ave., P.O. Box 2009,"Stk., CA 95261 M FEE, AMOUNT DUE , AMOUNT REMITTED RECEIVED,BY i DATE PERMIT`NO. INFO 1 ' +EH 13-24(REV.1 85) - # -' - c" /tel - +AT EH 14-26