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F APPLICATION FOR PERMIT SAN JOAQUIN LOCAL. HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA V" 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 oa i*Coungyinape No.544afor sewage of No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. )I Jf�T10 Job Address 1 `,`2_.�OaS,t h��-T)City Cwt Lot Size �I�94-7 V-7-1 PM Owner's Name Address Phone 93G Z323 C67 Q415) Contractor Address License No. 5-5"02.a5 Phone 5 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER �A `C 4TecaiNlCAI At2t DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS N INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS � h, �' `�s ❑ Industrial 0 Open Bottom ❑ Manteca Dia. of Well Excavation_,(ii Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack �A Tracy Type of Casing Specifications r I'1 Public F Other 171 Delta Depth of Grout Seal 10, - I,S Type of Grout9p-aGY. I I Irrigation —.-Approx. Depth I I Eastern Surface Seal Installed by - Repair Work Done L7 Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter �__..� Sealing Material (top 50') Depth In 1'S r Filler Material (Below 50') -- TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIRIADDITION l I DESTRUCTION € I (No septic system permitted if public sewer is available within 200 feet.) 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 CI No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I 1 Depth Size T 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 Di§lrict. 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 all f 1111 re ired inspections. Complete drawing on reverse side. /0? Signed J Title: w-F f'�1C�ti3�1�:'f;- Date: CD R DEPARTMENT USE ONLY Application Accepted by Date ' _Area �C 411 1,7Pit or Grout Inspection by Date Final Inspection by / Date d Additional Comments: o w ❑ Stk 466-6781 ❑ Lor, 369-362f ❑ Manteca 823-7104 ❑ Tracy 835-6385 3 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 4V f`v IFEE NFO AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT-NO. €, aEH13-24(REV.1/Ks) � � /�,� 60—aA EH 14-26