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1.: APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE i ON AVE., STOCKTON, CA Fi Telephone (209) 466.6781 PERMIT EXPIRES 'I 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 Sa J aquin County Ta No.549 for seag or 1 for well/p and a Rules and Regulations of the San Joaquin Local Health District. i r/;moi-(� ,.f Xw .k,, c r y /"yl� ` Job Address / j( cZ ��' : _ City Lot Size / PM Owner's Name e Address ? .. 4 Phone � F A Contractor ® dress � �VA License No. Phone / ;.S /2 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ - 1DESTRUCTION ❑ 3 PUMP INSTALLATION ❑i SYSTEM REPAIR ❑ OTHER ❑ - f DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES --- DISPOSAU FLD. -- PROP. LINE 4 FOUNDATION AGRICULTURE WELL OTHER WE'LL,-,,– �d P_I_TS/SUMPS 1 INTENDED USE TYPE OF WELL PROBLEMAREA CONSTRUCTION SPECIF.ICATION643N4,� ❑ Industrial ❑ Open Bottom ❑ Manteca _Dia. of Well Excavation. Dia.,of Well Casing (y� ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications _ { ❑ Pub lic El Other 11 Delta Depth of Grout Seal Type of.Grout F { ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done (❑ Type of Pump H.P. State Work Done I Well Destruction 0 Well Diameter Sealing Material (top 50') ! Depth Filler Material (Below 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION ❑ (No septic system permitted if public sewer is j available within 200 feet jl Installation will serve: Residence— Commercial— Other } f . Number of tieing units: Number of bedrooms Character of soil to a depth of 3 feet: AWater table depth tYSEPTIC"TANK ❑ Type/Mfg Capacity No. Compartments L. PKG. TREATMENT PLT- ❑ Method of Disposal i Distance to nearest: WellFoundation Property Line �Q FLEACHING LINE ❑ No. & Length of lines Total length/size ' 1 F ER BED ❑ Distance to nearest: Well Foundation Property Line EEPAGE PITS ❑ Depth Size u her SUMPS Ll to near t: Well d Foundation 7 Property Line ' DISPOSAL PONDS � ❑ I Hereby certif at I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and ru regulations of the San Joaquin Local Health'District. i 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, Ihall 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 thisermit is issued, I shall employ p p Y persons subject to workman's compensa- tion laws of California." The appllc must call,for Ire 'ed ins ctions. Com fete drawin qw pe p g on reverse side. Signed X �` Title: Date: P6-L9 _$ � lrr ? F DEPA -ENT USE ONLY }'A licatioh'Accepted by 1 Date "" qL Area ' Pit Grout Inspection by ` K e 'z ate 9'�1 Gi Final spection by �Vxs s Additional Comments: i L7 Stk 4666781 'f❑ Lodi 369- 1 Ej"Qanteca° 623-7104 ❑ Tracy 835-6385 Applicant - 94't[lrn all copies to: vironmen#al Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2 Stk., CA 95201 .1rt�9V . { I I INFO FEE AMOUNT AMOUNT REMITTED CASH RECEIVED BY DATE 4141WNO. � , w {+ E1 (RM-24 1fli�fl5l r EH 144-26