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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON 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 Ordinance No.549 for se age or N:30o. 1851 for well/ ump and the Rules and Regulations of the San Joaquin Local Health District. ,!!J 72 D(AI1011�[_ N Job Address C16 �` IbG City�'�" of Size PM Owner's Name [,max 413 Address tJ Lam,["ZP4 &t!�phone t 6 —3S I /AAContractor's Name Z �'�cense No. 9-5cZ- Ph one TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ I� PUMP INSTALLATION ElSYSTEM REPAIR ElOTHER ❑ 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 Bottom ff 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 50'1 Depth Filler Material (Below 50') TYPE OF S-PTM-WORK: NEW,INSTALLATION REPAIR/ADDITION LlDESTRUCTION 13 (No septic system-permitted if public sewer is available within 200 feet.) Installation will serve: Residence— Commercial IK Other—\ f Numper of living units: kember of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK Type/Mfg __ ► Cap city LNo. Compartments l PKG. TREATMENT PLT. El Method of Disposal ,Distance to nearest: Well Foundation tM / Property Line 4_- ;T ._� LEACHING LINE )< No. & Length of lines Total length/size forn �, � FILTER BED E3 Distance to nearest: Well Foundation #'. C3� Property Line 4! s SEEPAGE PITS 'Of Depth Size (Number _ SUMPS ❑ Distance to nearest: Well Foundation Property Linet"_15L "` DISPOSAL PONDS ❑ hereby certify that I have prepared this application and that the work wilt 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 become subs ct to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the following:"I ce th n t e performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." ` r The applicant must c fo I equ' inspections. Complete drawing on r ersesid \\ Signed Title: Date: FOR DEPARTMENT USE ONLY�1 Application Accepted by Date G Area �� Pit or Grout Inspection//by,' Date �5 Final Inspection by Date /V65 dditional Comments:4-0 14 Ps 0 ZeZ IL A Stk 466.6781 ❑ Lodi 369-3621 ❑ Manteca 7104 ❑ Tracy 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 N0. INFO CASH + EH 13-241REV.10/83) ./ a13Sail