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... �, APPLICATION FOR PERMIT ,,/, SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE 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 fo�wage�r,No. 1862 for well/pump and the Ryles and Regulations of the San Joaquin Local Health District. �Y7d0 S�' U��£ ,�//�� Job Address d 180)c 'g© Ci Lot Size /J -GPM Owner's Name eZell '�`0 Address / Phone Contractor l " Address X License No. 09 Phone O TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑. OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES ' DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBI EM AREA .CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑'Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy :Type ofYCasing Specifications ❑ Public ❑ Other ❑ Delta ;Depth of Grout Seal Type of Grout -- ❑ Irrigation L--Approx. Depth ❑ Eastern "Surface Seal Installed by I Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction El Well Diameter Sealing Material (top 501 i Depth Filler Material (Below 501 - - TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/-ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is z// available within 200 feet.) t Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: ,e Water table depth Q SEPTIC TANK -�� // i'YType/Mfg GCapacity I`?j Oa No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE a--*`No. & Length of lines ?1.2 G74— �' TdTal length/size FILTER BED ❑ Distance Tonearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size umber .� SUMPS ❑ 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 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 followin :"I certify that in the performance of the work for which this permit is issued;I shall employ persons subject to workmanis compensa- tion laws of Calif ni .' The applicant u c or I u ed i pectio Complete drawing on r rse side Signed Title: Date; 1� FOR DEPARTMENT USE ONLY - M Application Accepted by �`�' Date' – Area 7 Pit or Grout Inspection t Date Final Inspectionl by' Date r` Additional Conpments: /y �/j/r�C Cis/ /ycS " 4 ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835 Applicant- Return all copies to: Environmental ealth Pe i /Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 INFO FEE [:7OUNT DUE AMOUNT RE ITTED CASHRECEIVED BY DATE PERMITNO. JEH 13-24(REV.1/85) S° EH 1426