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APPLICATION FOR PERMIT !I , SAN JOAQUIN LOCAL HEALTH DISTRICT I' 1601 E. HAZEL T ON AVE.,,STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1,YEAR FROM DATE ISSUED t ,.... .. .. .(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 made in compliance with San Joaquin County Ordinance No. 549 far sew1age or-No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. 1� x ' IYpYpYpI I Job Address City Lot Size,5/9 PM Owner's Name Address Address _ Phvne Reed Contractor aAddressLicense No.�190- 'I Phone �cJ! TYPE OF WELL/PUMP: il� NEW WELL WELIL REPLACEMENT ❑ DESTRUCTION EII PUMPINSTALLATIONN( �6$TEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK A(`?_l)r _ SEWER LINES /UBrl)(= DISPOSAL FLD.®l W—C"i PROP. LINE FOU"DATION k I'JE` AGRICULTURE WELL ��OTHER WELL PITS/SUMPS X INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial' ❑ Open Bottom ❑ Manteca bia. of Well Excavation _ Dia. of Well Casing (_ u Domestic/Private Gravel Pack ❑ Tracy Type of Casing /CCS _ Specifications # ❑ Public ❑ Other ❑ Delta Depth of Grout Seal [50 Type of Grout ❑Irrigation ----Approx. Depth ' ❑ Eastern Surface,Seal Installed by lL Repair Work pane Ll Type dkf Pump A_� H.P, State Work Done Well Destruction El Well Diameter C ,05 Sealing Material (top 5b') _ Depth 1M 0 Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW'INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is �----�------'--��- ----�-'r^- avallabie-within-200-feet.1— "` Installation will serve: Residence_ Commercial_ Other p Number of living units: ,i��Number of bedrooms } �, Character of soil to a depth of 3 feet: Water table depth 1 - r SEPTIC TANK ❑ Type/Mfg Capacity No, Compartments v PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well ,� Foundation Property Line F 1 I r LEACHING LINE ❑ No�& Length of lines fir' Total length/size 1 v FILTER BED ❑ Distance to nearest: Well it Foundation .Property Line { s I: SEEPAGE PITS j ❑ Depth Size ' Number +� F SUMPS .. �_ ❑ Distance to nearest:- Well Foundation Property Line s 4 DISPOSAL PONDS ❑ $- 11 r { 1 I hereby certify that i have prepared this application and that the work 611 be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health pisfrict.,.. 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 wrkorkman's compensation laws-of_C,alifornia-"Contractor's hiring or sub-contracting signature at certifies the following:"I certify thin the performance of the-wofor which this permit is issued,I shall employ persons subject to workman's compensa- tion laws of California." The applicanst call for all required in ttions. Comp)' drawing on reverse side. 1 x a yy tt to ; yl— Signed - _ I'I � Title: e t72 13 Qf Date: i = FOR DEPARTMENT USE ONLY- {f Application Accepted by Date 1 - `_�' Area zq Fit or rou pection b i Date `� `S'"� Final.Inspection by _ Date � k 3 Additional Comments: �� l ❑ Stk 466-6781 ❑ Lodi 3621 El M' 823-7104 ❑ Tracy 835.6385 Applicant - Return}all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave.,.P.O. Box 2009; Stk., CA 95241 Ii. INFO -7'AMOUNT;jDUE -- —AMOUN: Rf kffED`'"-''i�'GK' -" RECEIVED i3Y_' DATE +'EH 13-24IRn ' EV.tis) 1., ..5 �'1��;, /J7 SID l3 ! Eii14- -„- �r '7 �"L�— "W rl .II