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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT �} 1601 E. HAZE i 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 forsewa 8 or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address ��, �e#L0A1 PL40T,9 ` AO city ERRH/,V6 4)/"Lot Size 4 % 4C PM ' Owner's Name L C d Address F SO TIAIWIAJ AID Phone _V_ Contractor -Address License No. Phone TYPE OF WELLIPUMP- NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ F DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL—. PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private E71Gravel Pack 1-1Tracy Type of Casing Specifications M Public ❑ Other Cl Delta Depth of Grout Seal Type of Grout 1 1 Irrigation —.Approx. Depth 1 I Eastern Surface Seal installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction 0 , Well Diameter.. Sealing Material (top 501 1 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW.INSTALLATION REPAIR/ADDITION i.I DESTRUCTION l I (No septic system permitted if public sewer is available within 200 feet.) „Installation will serve: Residence Commercial Other R P Number of living units: —,(— Number of bedrooms Character of soil to a depth of 3 feet: Aw - Water table depth ry SEPTIC TANK Type/Mfg �- opacity r 2, o E� No. Compartments l PKG. TREATMENT PLT.C1 n Method of..,Disposal + Distance to nearest: Welles Foundation r r Property.Line_tom LEACHING LINE `" Y_ No. & Length of lines &iMf Total length/size s R. FILTER BED ❑ Distance to nearest: Well Foundation 13Q_".— Property Line "SEEPAGE PITS Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation 1 Property Line ..— DISPOSAL PONDS ❑ E 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 Di3trict. 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 must call far all re ad inspections. Complete drawing on reverse side. ,A SignedTitle: Date:%"/ �Z ONLY Application Acceptedby' �//{ rw�nZ - Date Area Pit or Grout Inspection byDate Final Inspection by Date Ei S� Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 C1 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 OUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMITNO. INFO rj..EH13-244REV.1/85) ) A �1EH14-29 - `�O•� iJ pG61 17 t y