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A PLICATION FOR PERMIT ��YSAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE. STOCKTON CA Telephone (209) 466-6781 PERMIT EXPIRES i YEAR FROM DATE ISSUED S' (Co e e iTriplicate) Application is hereby made to the San Joaquin Lqcal Health District for a permi construct and/or install the work herein described.This application is made in compliance with San n Co rdi nce Nor for well/pump and the Rules and Regulations of the San Joaquin Local Health District. �� : FFG+// Job Address City -of 3 A em Owner's Name dress ho'ne / Contractor's Name ��/f`' se No. TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ / PUMP INSTALLATION 5L--- SYSTEM REPAIR ❑ OTHER ❑ { DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE , fr FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS y INTENDED USE TYPE OF WELL PROBLEM AREA ,CONSTRUCTION SPECIFICATIONS ❑ Industrialen Bottom ❑ Manteca .� Dia. of Well Excavation Dia. of Well Casing Z-lZmestic/Private ❑ Gravel Pack ❑ Tracy\\ '� Type-of Casing ,, Specifications 1d ❑ Public ❑ Other ❑ Delta %,Depth'of Grout Seal Type of ut ❑ Irrigation pprox. Depth EJ st tern" r _ —f Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P._2- State Work Done Weil Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 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 Other 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. TREATMEN,r PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line ( s LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ 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. 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, 1 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 California." The applicant mu call or all required inspections. Com ete rawing on reverse side. Signed X, ��I Title: _- Date: A.? SE ONLY ZDEPARTMENT / Application Accepted by' Dates _1' 6- Area Ph or Grout Inspection by Date final Inspection by DateOV Additional Comments: ❑ Stk 466-8781 odi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-631 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2008, Stk., CA 95201 t FEE INFO AMOUNT DUE AMOUNT REMITTED C SH RECEIVED BY DATE/ PE/RMIT"NO. s% + EH 13-24(REV.10/831 EH 1426 © ��^ f F✓� CS{/ �/ i1igO O"��{� IG'��/