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APPLICATION FOR PERMIT A. SAN JOAQUIN LOCAL HEALTH DISTRICT (� 1601 E. HAZEL T ON AVE., STOCKTON, CA I Telephone (209) 466-67$1 't o P4&i4J PERMIT EXPIRES 1 YEAR FROM DATE ISSUED IComplete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is made in compliance with San Joaquin County Ordinance NO. 549 for se%age or No. 1862 forwel/pump and the Rulus and Regulations of the Sah Joaquin Local Health District. 171�� //�-CaC 7 Job Address t�$All/�nnitli°r uN �i�wcP�I h InaL«lC�y/ 1City Lot Size�� %^ia•� PM z� A ' . IZ hone 1 Owner's Name Lc11 6k Address J-��Q -C,cry r ��siPhone ""�Sa2 a! Contractor St°n Address +� License No.Wsssy Phone � TYPE OF WELL/PUMP: v NEW WELL�( WELL REPLACEMENT ❑ DESTRUCTION ❑ j t PUMP INSTALLATION ' SYSTEM REPAIR ❑ OTHER ❑ O t �c DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES A DISPOSAL FLO. PROP. LINE �� FOUNDATION AGRICULTURE WELL OTHER WELL ✓�j PITS/SUMPS _ - E INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 11 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation A2 Dia. of Well Casing Domestic/Private. Gravel Pack ❑ Tracy 1 Type of Casing-44V(_ Specifications /de f l Public Ill Other ❑ Delta Depth of Grout Seal �� ! Type of Grout 9 I Irrigation —Approx. Depths 1.1 Eastern S, ' Surface Seal Installed by „ Zh rF _ Repair Work Done L] Type of Pump _4, H.P. J7 State Work Done Well Destruction -�❑ Well Diameter y Sealing Material Itop 50'1 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I I»REPAIR/ADDITION l I DESTRUCTION I I INo septic system permitted it 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 i PKG. TREATMENT PLT. ❑ n Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size L FILTER BED ❑ Distance to nearest: Well Foundation PropertyLine SEEPAGE PITS l'1 Depth Size _ 1 Numher7l SUMPS C1 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 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 fat for al quired i cti s. Complete drawing on reverse side. Signed X Title: Date: FOR DEPARTME T USE ONLY Application Accepted by Date 6 A1 Area Pito Gro Inspection by Date Final Inspection by Date Additional Comments: " ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 635-6385 S I� Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 r FEE INFO AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY HATE PERMIT'NO. z +.EH 13-24(FIEV.1/H 5) ��-�s93 f� EH 1428 /