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Y APPLICA ON FOR PERMIT T ' SAN JOA QUIN LOCAL HEALTH DISTRICT € t4vi �� • 1601 E. HAZE'T ON AVE., STOCKTON, CA Tetepho'a (209) 466-6781 PERMIT EXPIRES-1 YEAR--FROM DATE 19SUED ( (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 Joaquin County Ordinan r swage o o. 1862 for well/pump and the flutes and Regulations of the San Joaquin Local Health District. �,}� ©(o,s 3oC)� y Job Address City Lot Size PM � r ' Efi - Phone Owner's Namet� aEtt3 !d- Address . - Contractor ddress ! A41 a icense No.6%151&L Phone_ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION ❑ i PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ �YI]I$TANCE'TO-"N EAREST:'SEPTlC'TANK' SEWER LINES `DISPOSA[''FLD. PROP.`tINE` FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS ` INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS r ❑ Industrial-r� ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Cl Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications �? , F1 Public f f Other i I-.] Delta Depth of Grout Seal Type of Grout f I I Irrigation Approx. Depth l I Eastern Surff ce Seal Installed by - Repair Work Done ❑ Type of Primp H.P.�/5� State Work Done WelIDestruction ❑ Well Diameter !� Sealing Material (tap 50') I Depth n. I;ZR!! _ Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION (I REPAIR/ADDITION l I DESTRUCTION l I INo septic system permitted if public sewer is ryy "f available within 200 feet.) `1! Installation will serve: Residence Commercial _ Other Number of living units: Number of bedrooms i Character of soil to a depth of 3 feet: Water table depth, T_ SEPTIC TANK ❑ Type/Mfg Capacity__ No. Compartments .i . PKG. TREATMENT PLT. D Method of Disposal q i Distance to nearest: Well Foundation Property LineJkL 1 LEACHING LINE ❑ No. & Length of lines Total length/size _ _ _ FILTER BED ❑ Distance to nearest: Well Foundation Property Line .'`i 1i�1ENTAL HFA; �'• t 1s fig^ t t ,A SEEPAGE PITS 11 Depth Size Number I ...:„ - -E. -�. _ �+- p J - _ -W - . . ; SUMPS..T � ❑—Distance to nearest: Well Foundation Property Line Il DISPOSAL PONDS ❑ f 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 1 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 follow' : "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 Car t rn -' The applicari u call for all requir inspection . omplete drawing on ve s side. ` Signed X Title- Date: { FOR 0 PARTME USE ONLY F _ Application Accepted by Dater' r. Area I Pit or GroutInspectionby r Dato Final IInn�'pectton by� Date �U s I � � y / C Additional Comments: `_ � ��'�' °-` 4 ❑ Stk 466-6781 f ❑ Lodi 369-3621 El Manteca 823-7104 ❑ Tracy 835- Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Heielton Ave., P.O. Box 2009, Stk., CA 9501 t, FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT•NO. INFOASH {/f C t.EH 13-24 IREV.i/n sl) S� C_S� /J EH 14-28 I k�