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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 Countyrdinance N 54 for swage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. /FM 71W Job Address AI.OINe ALZ( 4NCity S�Oc�r/Al Lot Size �a "fzYIS PM Owner's Name AMt°Lt� u 6iGf1 r•0iL/C S Address @ lfbaye Phone b�s bz Contractory• 17• K�f l/J �(�Pr Address i7-/5V (J Yf/ License No.47 `ZJr� Phone IM-Sid-17401- TYPE - 66-17TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER 1N o n t-�.er�+� 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 1 Dia. of Well Casing T ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing P 116A4r)V[1S5 Specifications f'1 Public ❑ Other 71 Delta Depth of Grout Seal 161, J Type of Grouts{x.11 aoM'1 I I Irrigation 1•-P—Approx. Depth I 1 Eastern Surface Seal Installed by 1<L61NElF71l/F_R - Repair Work Done ❑ Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material (top 50') HOWi�O/rN W �L� Depth Filler Material (Below 50'1 TYPE OF EPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I I INo 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 ❑ 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." Contractors 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 applican must call for allr ins tions. Complete drawing on reverse 'si/de. Signed X CC Title: 'StW ltd e eo/e4l4 Date: 4 FOR DEPARTMENT USE ONLY o. Application Accepted by P-5 Date— o Area O Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: )IFy A-7T14GH a 6gT ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6395 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 CK INFO I r RECEIVED BV DATE PERMITNO. In1��1 // �j �Z S EH 11-2a &3-24IREY.tixs) EN 13S _ ', ,- 'w✓ 1747 � 232-�