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t� APPLICATION FOR PERMIT U SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE„ STOCKTON, CA Telephone (209) 466-6781 b PERMIT NO. SRN JppQU4N LOCAL PERMIT EXPIRES 1 YEAR FROM DATE ISSUED DATE ISSUED �EpLTH DtiSTR[CTi (corr�let�e in plica Appl'cation 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 Count Ordinance No. 549 for sewa a or No. 1862 forwell and the Rules Regulatio of the San Joaquin Local H Yt Y District. y 9 /Pump Job Address f R h 4e- i- ubdivision Name t�e>'7_ZS o fo Owner's Name 9 Address 3 Contractor's Name one �7 �`3 License No. Phone `� 3� TYPE OF WELL/PUMP WORK: NEW WELL [E�_ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION rj. SYSTEM REPAIR ❑ OTHER [J �} DISTANCE TO NEAREST: SEPTIC TANK �(1 SEWER LINES �"'(� DISPOSAL FLO. PROP. LINE 'v FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 1-1 Industrial — U pen Bottom ❑ Manteca Dia. of Well Excavation f �mestic/Private ❑ Gravel Pack Trac �- F F] Public y Dia. of Well Casing r ❑Other ❑ Delta Irrigation Approx. ❑ Eastern Type of Casing ❑ Cathodic Protection Depth Specifications /� 1 L] Geophysical Depth of Grout Seal 0ther Type of Grout _ -� C, Surface Seal Installed by Repair Work 0vne [:] Type of Pump H,P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 501) TY54F SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION (No septic tank or seepage pit permitted if public sewer is Installation will serve: Residence — Commercial Other available within 200 feet.) Number of livingunits: --�' Number of bedrooms Lot size ,�� Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Ca acit CD P y No, Compartments PKG. TREATMENT PLT. ❑ Type/Mfg __7 Capacity Method of Disposal SEWAGE SYSTEM I� Distance to nearest: Well Foundation DESTRUCTION Property Line LEACHING LINE ❑ No. & Length of lines Total length/size . FILTER BED ❑ Distance to nearest: Well Foundation Property Line d SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation- Property Line I, DISPOSAL PONDS C� 1 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!i 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 compensation laws of California." The applicant must call for tUvequired inspections, Complete drawing on reverse side. Signed XV��s•�':►\1 Title: Date: ,` OR DEPARTME USE ONLY �1� Application Accepted by Area Q� ❑ Stk 466-6781 Additions omments: Lodi 369-3621 Pit or G ou Inspection by Date ❑ Manteca 623-7104 Final Inspection by 4virn ate �y ❑ Tracy 835-6385 Applicant - Return all copies o: Enal Healt Permit/Services 1 E, H ze�1L P.O. Box 2009, St k., CA 95201 FEE BASE AMOUNT DUE AMOUNT :REMITTED RECEIVED BY DATE PERMIT NO. INFO EH 13-24 REV. 10/82 IO182 500 14-26 tZt53