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APPLICATION FOR PERMIT y r ' SAN JOAQUIN LOCAL HEALTH DISTRICT ➢., F ' 4r� •. 1601 E. HAZELTON AVE., STOCKTON, CA• Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED x f ��. (Complete in Triplicate) -,. Joaquin local Health District for a permit to construct and/or install the work herein described. This application is Application is hereby made to the San e or No. 1862 for well/pump and the Ryles and Regulations of the San Joaquin made in compliance with San Joaquin County Ordinance No.549 for sewag Local Health District. Job Address Y t City L L 7dI' Lot Size !27 145-2PMQLD®f -Owner's Name Address c . –Phone 2 I j Contractor L X dress 2�� S L=z I AO�—L'+cense No./4C �I ' Phone /1'1 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 A INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS W L1 Industrial Q Open Bottom ❑ Manteca =Dia. of Well'Excavation Dia. of Well Casing C3-Domestic/Private 11Gravel Pack IDTracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta - Depth of Grout Seal Type of Grout ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by k Repair Work Done ❑ Type of Pump H,P. State WorI Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 501 TYPE-OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITIOiW DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) t r Installation will serve: Residence)<, Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: L Water table depth k SEPTIC TANK Type/Mfg 4 apacityAffme No: Compartments PKG. TREATMENT PLT. ❑ Method of Disposal F' Distance to nearest: Well Foundation Property Line LEACHING LINE XNo. & Length of lines Total.length/size 2 4 , FILTER BED XDistance to nearest: Well 0�9, Foundation y'�i[�_ Property Line 1r ._ SEEPAGE PITS Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line i DISPOSAL PONDS ❑ ill be done in accordance with San Joaquin county ordinances, state laws, and I hereby certify that I have prepared this application and that the work w + 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- I tion laws of California. ? The applicant must call for all req ry spections. Com ete drawing on reverse side. Signe Title: Date: FOR DEPARTMENT USE ONLY L/ Date 7" Area , Application Accepted by 1 Date Pit or Grout Inspection by Date Final Inspection by F Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ 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 FEEAMOUNT DUE AMOUNT REMITTED CASH CK 0 RECEIVED BY f DATE PERMIT NO. F� INFO F + EH13-24iREV.1/a51 14S.66 EH 14-26