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. 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 (Complete in Triplicate) CL Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein ciesb4ed. Tltis application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for weVpump and the Rules and Regulations of the San Joaquin Local Health District. well &5,4!�- ,9 Job Address <- City f Lot Size PM ^ZS - Q Owner's Name R1 J901'Z� Address 1'' �-ST 's� ' Phone ContractorRr✓` '^ ' Address � � � License Na�b-�00 Phones" TYPE OF WELL/PUMP: N WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION t7 SYS REPAIR ❑ OTHERX/4(Mj*r,n7Well DISTANCE TO NEAREST: SEPTIC TANK NA_..__ SEWER LINE -6Q " DISPOSAL FLD. N1 PROP. LINE`-Z// FOUNDATION /40 AGRICULTURE WELL 6 OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATION ❑ Industrial 0 Open Bottom ❑ Manteca Dia. of Well Excavation � � Dia. of W�Casing .:r L1 Domestic/Private L-1Gravel Pat;k ❑ Tracy Type of Casing PYCSpecifications f M Public ❑``Other I r ❑ Delta Depth of Grout Seal2 Q Q Type of Grout0-p�Pn�u� I I Irrigation ��?40Approx. Depth l I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material Itop 50') Depth A Filler Material IBelow 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ['I REPAIRIADDITION f I DESTRUCTION I 1 lNo septic system permitted if public sewer is available within 200 feet.) Installation will.serve: Residence Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet! Water table depth 1 , SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ 'I Method of-Disposal Distance to nearest: Well Foundation Property Line . kl LEACHING LINE ❑ No. & Lehgth of lines Total length/size r; FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS [ I Depth I Size Number SUMPS 0 Distance !to nearest: Well Foundation 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 ust call for alluired ' s actions. on drawing on reverse side. Signed X " Titlea7pp��n� °1r�= Date: f FQfMEPAVM USE ONLY Applicatio Accepted by Date Area !f Pit or rout nspection by Date / Final Inspection Date ✓�v Additional Comments: i f ❑ Stk 466-6781 0 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 RECEIVED BY DATE PERMIT'NO. C +.EH 13-241REV.1/n5Y - _ C� ` EH 14-2e `L � c 1\ O F "� 1 App 1 icolnk /75 nestle -S pi OWrier 5 ty ipon. greeme1V-0 c ed