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' APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT I 1601 E. HAZELTON AVE., STOCKTON, CA ` Telephone (209) 466-6781 4 M94 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED AIN (;/`:. liilV LUGAL (Complete in Triplicate) a HEAL I'H 1)ISTRIC T 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 wit San Joaquin Cour!tyOrdinance No.549 for s age or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. /i 3 o EJob Address �.-'7 b��"�� //,,"//�,�//77/1L�� /—y City � A/� Lot Size PM Owner's Name5?A(/*!/ ,' _S Address " �JU , t hh /�a � Phone Contractor's NameTffe License No. �/Q /40 Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR Cl OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK OW 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 ns ❑�Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation Ad2Approx. Depth Q EasternSyrface Seal Installed by Repair Work Done ❑ Type of Pump H.P. /A State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted 8 public sewer is available within 200 feet.) W 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 1 ) PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line y SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and e 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 to become subject to workman's compensation laws of California."Contractoes 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 mm at call for all required inspections. Complete drawing ' oCn'reverse /side SignedTitle: Date: FOR DEPARTMENT USE ONLY Application Accepted byyy Date T Area Pit or Grout Inspection by Date Final Inspection by Additional Comments: _ ❑ Stk 466-6781 ❑ Lodi 369-3621 O Manteca 823.7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1801 E. Hazehon Ave., P.O. Box 2009, Silk., CA 95201 FEE INFO AMOUNT DUE -AMOUNT REMITTED CASH RECEIVED BY t�•� DATE PERMIT NO. r EH 11U IeEV. 10/831 HSI d6 YI7 C4 EH 1426 1-� r i