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APPLICATION FOR PERMIT • SAN JOAQU®I� ALTH D ^VISTRICT �y 1601 E. HAZEL ()TOCKTON, CA Tel 6-6781 PERMIT EXPIREPa+1Wea �44Q69M DATE ISSUED Application is hereby made to the San Joaquin Local Health Pufauq,20 r�4 r�R"iM)WQ f/or install the work herein described. This application is made in compliance with San Joaquin County Ordinance"VAROWA oro. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. ��` Job Address /y 2 C"'D� 'Jy� City j d Lot Size PM Owner's Name '�z � ��' Address • 7574/p�4 Z' �V Phone $4 Z�J Contractor LQGJrmce, Address � 7 License No. Phone_ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ i PUMP INSTALLATION)( SYSTEM REPAIR ❑ l)OT�HER El DISTANCE TO NEAREST: SEPTIC TANK �a.�� SEWER LINES 7S�J DISPOSAL FLD.�'�Z PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications I'! Public Ll Other ❑ Delta Depth of Grout Seal Type of Grout I I Irrigation ___ Approx. Depth I I Eastern Surface Seal Installed by _ Repair Work Done Ll Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 50') _ TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I 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 Ll No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size 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 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 applicantjfipst call for all required inspections. Complete drawing on reverse side. Signed X1�f/ l/ c�� Title: ��r Date: OR DEPARTMENT USE ONLY Application Accepted by Date Pit or Grout Inspection byDate Final Inspection by Date 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 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO ♦ EH 13-24(REV.I/H5) Q EH 14-26