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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON 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 for a permit to construct and/or install the work herein described. This application is made in compliance with San Joaquin County Ordinance No.. 9 for Or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. fil r U i�, P � Job Address �--% City Lot Size PM iC b Owner's Name tyMV � � rA�drdr'e1ss + Phone Contractor z)f+l Address "T�T� �� 11 dyy ' License No. 0 Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP-INSTALLATION 1e SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. 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 M Dia. of Well Casing [I Domestic/Private Gravel Pack ❑ Tracy Type of Casing �. Specifications II/Public CI.Other l l Delta D?th of Grout Seal `Type of Grout y I i Irrigation :_Approx. Depth l I Eastern Surface-.Seal Installed by Repair Work Done ❑ Type of Pump H.P. r State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material Melow 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION (I REPAIR/ADDITION I I DESTRUCTION In ANo septic system permitted if public sewer is available within 200 feet.I Installation will serve: Residence_ Commercial — Other Number of living units: Number of bedrooms I Character of sail to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg ` Capacity 4 No. Compartments PKG. TREATMENT PLT. © , Method of Disposal Distance'to-nearest: Well `Foundation_ _ Property Line r LEACHING LINE ❑ No. & Length of lines Total length/size } ti- Y FILTER BED Cl 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 ❑ J 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 foil win : 'I a ify that in th rtormance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws alifor, The app.cant ust for 11 r it tions. Complete drawing on re or a�1e. dzov Signed Title: ✓ 'i r Date: FOR DEPARTMENT USE ONLY --- Application Accepted by Date IJ r / Area Pit or Grout Inspection by Date Final Inspection byG Date i Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7144 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 INFO FEEA}MO�U'NT DUE AMOUNT REMITTED CASH RECEIVED BY / DATE PPEERMiT NO, + EH 13-24(REV. /n51 EH N-28 -?If- � rG� �J/ f — � ` Lr� ✓fff//i