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�v?1�--k e APPLICATION FOR PERMIT Q� SAN JOAQUIN LOCAL HEALTH DISTRICT C' 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 (�7 - cS 6- y%i CK' PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (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 for oro. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. �J Job Address /'�O/( r /��fL /� ]C CC, City (n) � / /'Lot Size�0 C-CA e.L pM Owner's Name l �L-a..-9 / ,C!i ,'C L Address n�Sj_�,_fJ Y t1>Zn 7� cY jrone J ContractQ4� 1. Address �f ` G��jn License No. � L.7 phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Q 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 ❑ Industrial ❑ Open B m— ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION lY REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence V Commercial_ Other Number of living units: Number of droop s- cl r Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK V Type/Mfg 1 Capacity 4X No. Compartments PKG. TREATMENT PLT. ❑ r , Method of Disposal Distance to nearest: WellS�+ Foundation 16 Property Line y 1 f LEACHING LINE le'No. & Length of lines - (n Total length/size 1Q6z FILTER BED ❑ Distance to nearest: Welld r � ) t Foundation /U property Line S`r> - SEEPAGE PITS (�✓/Depth s Size Number `7f r SUMPS ❑ Distance to nearest: _ Well __Foundation r7 Property Line S +" DISPOSAL PONDS ❑ 1 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 at all for I req fired inspections. Complete drawing on reverse sid}e/, �Jt' `� /��, �7 Signed �� Title: \J. 1 ' Date: DC-7 -1 9 / FOR DEPARTMENT USE ONLY a Application Accepted by Date Area 6 Pit or Grout Inspection by Data Final Inspection by Date` J Additional Comments: ❑ Stk 4664781 ❑ 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 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH CK 4 RECEIVED By DATE PERMIT'NO. t EHI}N(REV.1/05) EH 141e ,