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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone 12091 466-6781 PERMIT EXPIRES 1'YEAR FROM DATE ISSUED (Complete in Triplicate) Application is he+eby 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 foKziswage o No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address v2TfGr' 204 el:5 y City Lot Size C- T PM Owners Name Address 1� � vv «J� �J9n Phone e Contractor r - �. ddfess �� License No..Jo4d zZ6 Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ 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 1-1 Public M Other n Delta Depth of Grout Seal Type of Grout I I Irrigation —..Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material Itop 501 Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION l I DESTRUCTION l I Wo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial_ Other Number of living units: --Z-- Number of bedrooms Character of soil to a depth�f 3 feet: Water table depth SEPTIC TANK C�1 Type/Mfg tc�cv Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well �� Foundation /t Property Line 2Sz LEACHING LINE No. & Length of lines 404t Total length/size FILTER BED ❑ Distance to nearest: Well Foundation iC Property Line .3C SEEPAGE PITS l Depth Size j z� Number SUMPS Ll Distance to nearest: Well Z 6Cr Foundation zip Property Line DISPOSAL PONDS ❑ 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, 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 California." The applicant must,call for all required inspections. Complete drawing on reverse side. Signed X 9 Title: Date: Sir 7 FOR DEPARTMENT USE ONLY f Application Accepted by Date �`� Araa Pit r Grout Inspection by ate Final Inspection by Date Additional Comments: ❑ Stk 466-6781 D 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 EE INFO AMOUNT DUE AMOUNT REMITTED CCK 9 RECEIVED BY DATE} PERMIT'NO. + EH 13-241REV.t/x51 EH 14-26