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APPLICATION:FOR PERMIT SAN JOAQUIN_LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON.AVE., STOCKTON, CA Telephone'(209) 466-6781 F 1 PERMIT EXPIRES 1 YEAR FROM:DATE ISSUED ., ,� z h. ,. •�. :. >.y., M . {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.5 9 for s9 s anegu ,wage r No. 1 for well/pump and the Ruled Rlations f the San Joaquin Local Health District. Job Address City. Loti Size PM r Owner's Name 2 ddress � � tlzA Phone Contractor Address ` Y License No.7��y� Phone r/Ows�2 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ i PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES I _ DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/BLIMPS I INTENDED USE TYPE OF WELL ,-�--PROBLEM"AREA CONSTRUCTION SPECIFICATIONS ❑"Industrial �tj� ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑Domestic/Private C1 Gravel Pack Q Trac "' T r Y Type off Casing Specifications 171 Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout r ❑ Irrigation —_Approx.}Depth ' Ll Eastern Surface Seal Installed by 3 Repair Work Done ❑ Type of Pump H.P.,. s State Work Done Well Destruction ❑ Well Diameter Sealing Material {top 50'I - r _ Depth' Filler Material (Belo_ 501 $ j TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ 'REPAIR/ADDITION tr DESTRUCTION ❑ INo septic system permitted if public sewer is r F available within 200 feet.) Installation will serve: Residence Commercial_ Other Number of living-units: Number of bedrooms- Character edroomsCharacter of soil to a depth of 3 feet: Water table depth SEPTICJANK ❑ Type/Mf t E 9: Capacity _ No. Compartments PKG. TREATMENT-.PLT,. ❑ T Method of Disposal .. � = .. Distance'to neatest: V Well Foundation" Property Line I LEACHING LINE ? CJ :NO. & Length of lines Total length/size f i FILTER BED t.•❑ Distance to nearest: We I i s I 3 o Property Line SEEPAGE PITS .' '❑ Depth Size JNumber _ AV SUMPS r r, p, Distance to nearest: Well Foundation T _ Property Line f I DISPOSAL PONDS ❑ I hereby certify that I have prepared this;pplication 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 4 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 em to tion laws of California." I p Y persons subject to workman's compensa- r The applica t must call for allquired i .spections. Complete drawing on reverse side. Signed k J R _` / r y Title: Date: }7 4 4. FOR DEPARTMENT USE ONLY ~c 7tion Acce ted byDate ` LZArea M_1ODrout In 4 pection by Date d' Final Inspection by Date �. Additional Comments: ❑ Stk 466-6781 ❑ 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 y INFO AMOUNT DU1-4� AMOUNT REMITTED CASH RECEIVED BY BATE PERMIT"NO.+ EH 13-24(REV.Fins) . '"" ! a � EH 1428 l 1