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r i - i APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE.,+STOCKTON, CA Telephone (209) 466-6781 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 Ord' anc No.549 for wage or No. 1062 for ell/pump and the Rules and Regulations of the San Joaquin 1 Local ocaHealth District. vr, �� .M� � 40 mgt> Job Address 1 �/� �' City �ca C i A Lot Size PM - + -Owner's Name CJ cJ$• Address Phone ' Contractor f Add �� e� License No. Phone TYPE OF WELL/PUMP: NEW WELL I!t— WELL REPLACEMENT ❑ DESTRUCTION ❑ 3 ..PUMP INSTALLATION l�Ff SYSTEM REPAIR❑ OTHER El DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS I INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Die- of Well Excavation Dia. of Well Casing domestic/Private n-Gravel Pack ❑ Tracy Type of Casing Specifications j ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout J ❑ Irrigation ---Approx. Deptht � ❑� Eastern Surface�S al Installed by e. 'k Repair Work Done f_1q Type of Pump � H.P. State Work Done Well Destruction ❑ Well Diameter L Sealing Material (top 501 Depth Filler Material IBelow 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is ` available within 200 feet.) Installation will se7depth ence— " Commercial_ Other NO Number of living ber of bedrooms +� Character of sail tof 3 feet:h Water table depth SEPTIC TANK ype/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: . Well Foundati Property Line LEACHING LINE ❑ No. &Length of lines Total length/siz FILTER BED f ❑. Distance to nearest: Well Foundation Property Line SEEPAGE PITS' ❑ Depth Size * Number '�� SUMPS ❑ Distance to nearest: Well Foundation 4 Property Line DISPOSAL PONDS ❑ t C" - 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 1 rules and regulations of the San Joaquin Local Health District. ; 1 Home owner or licensed agent's signature certifies the following: "t 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." Contractors hiring or sub-contracting signature. certifies the following:"I certify that in the performance of the work for which this permit's issued;I shall employ persons subject to workman's compensa- tion laws of California. The applicantrtfiu call for all mired ' pections. Complete drawing on reverse side. /!1r Si ned �1 `, u-All ( /p 4 g Title: * Date: i �r FOR DEPARTMENT USE ONLY l Appby lication cepted' "` I Dat E �Q� Area Pit o ou nspection by Date -�S Final Inspection by Date '. Addis anal Comments: ❑ Stk 466-6781 ❑ L i 369 3621 fl Manteca 023-7104 ❑ Tracy 835 6 Applicant-Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE # AMOUNT REMITTED RECEIVED BY DATE PERMIT'NO." INFO CAZn r + EH 1 -24IREV.1/851 7 EH 1418 d s {{