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3 . APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZETON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Cprnplete iri Triplicate) IF Application is hereby made to the San Joaquin Local Health Distrie .f.orA permit to construct and/or install the work herein described. This application is made in compliance with San Joaquin County Ordinance No. _ u-No, 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address D�0 City' <✓142C9•Lot Size 10 �y PM 'r:T Owner's Name ►!T1e— 6In e n Address Phone Contractor 1��4 III-f— Address 196 Y License No. 2 S75TaPhone 'l4aS TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLAGEMENT.❑ 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 El Industrial D Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private D Gravel Pack D Tracy Type of Casing Specifications 17 Public ❑ Other n Delta Depth of Grout Seal Type of Grout I I Irrigation _Approx. Depth { I Eastern Surface Seal Installed by • f I Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler MaCerial (Below 501 TYPE OF.SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I I DESTRUCTION l I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_-____ Commercial.-.r Other Number of living units: I Number of bedrooms 3 H Character of soil to a depth of 3 feet: _ _5'andy L td Water table depth SEPTIC TANK Type/Mfg !Pp221 C_ Capacity t4k�_ No. Compartments PKG. TREATMENT PLT. ❑ r 1 Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE e No. & Length of lines �_ Ira — lab Total length/size [ FILTER BED ❑ Distance to nearest: well I Foundation Property Line—�Jn SEEPAGE PITS l I Depth Size Number SUMPS ' Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 40. 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 shell 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 II for all jequired inspections. Complete drawing on reverse side. r Signed X JAI-- Title: ��a Date: f DEPARTMENT USE ONLY 1f Application Accepted by Date / " ' Area Pit or Grout Inspection byDate Final Inspection by Dat /f Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 El 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 INFO FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY {{ ��DATE PERMIT'NO. ♦.EH 1 3-24 IREV.1/8 51 ) 1-` '29EH 14-26 ! !