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APPLICATION FOR PERMIT 1V0 4/-/.rl 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) 1desc @ Application is hereby made to the San Joaquin local Health District for a permit to construct and/or install the woe Iier r ribed TMs appfl�d oaq is Re ell/pump and the Rules an gulations of the San Joaquin made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for w Local Health District. / '�{oY��i! PM Job Address S �hone v Owner's Name y/1^-� `� / Contractor A ddress // �``/ License No. /2,3 Pho11� r` TYPE OF WELL/PUMP: NE WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ N(^ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ v \ 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 ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private - ❑ Gravel Pack ❑ Tracy Type of Casing Specifications FI Public ❑}ther fl Delta Depth of Grout Seal Type of Grout_ I I Irrigation la-'// Approx.pDe I astern SyrfiJC@ Seal Installed by p Repair Work Done Type of Pum H.P. F/ �f State Work Done_ Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No vailaseptic within tem permitted mi ted if public sewer is 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 SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE Ll No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS Ll 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 li a '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 on in such man er as to be ome subje workman's compensation laws of California."Contractors hiring or sub-contracting signature certifies them "I certif hat in th rma a the work fo which this permit is issued, I shall employ persons subject to workman's compensa- tion laws California.' The appli nt m all re i atedrawi l Pit or Grout Inspection by ng o v s,do . /A Signed Tit e: �/ Date: F R VIEPARTMENT USE ONLY ra-�_ _ — Application Accepted by Date Area {- 11.1 Date Final Inspection by ` 9 2/�r7 Date`s 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 AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BV DATE PERMIT N0. NFO EH1124(REV.vxsi EX U-]6 ✓✓