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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL I 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 ffeorr aa�permit to construct and/or install the work herein described.This application is made in compliance with San Jo quin County Ordinance No.549 fo�� o. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. /g �p�j - Job Address ('(� S 4o ooe lis C'rry ` Lot Size �d I ��C1�1._ PM Owner's NameliSti► StIl W gwytZ ! " Address Q`LVPhone Contractor's Name =0 License No. :3 SA-2 7 Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES _/_7�� T DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIE TION If ❑ Industrial ❑ Open Bottom 0 MMariteca Dia. of Well Excavation Dia. of Well Casing Cq ❑ Domestic/Private ❑ Gravel Pack +& racy Type of Casing S Specifications /� ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout Ole ` ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done 0 Type of Pump H.P. State Work one Well Destruction ❑ Well Diameter Sealing Material [top 501 tAntim 7-- Depth Filler Material {Below 501 a TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) ' - -Installatiorr will servo: Reside nce - 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 y 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 SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 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 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 call for=red inspections. Complete drawing on reverse side. Signed /` Title: Date: R DEPARTMENT USE ONLY Application Accepted by Data 7 Area Na Pit or Grout inspection by Date Final inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3821 ❑ 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 IFEE NFO AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY DATE PERMIT'NO. + EH 1128(REV.10/831 �I$f T ��.p