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Well Site APPLICATION FOR PERMIT I SAN JOAQUIN LOCAL HEALTH DISTRICT = " 1601 E. HAZEL T ON AVE„ STOCKTON, CA n L rr !� Telephone 12091 466-6781 II PERMIT EXPIRES TYEAR FROM DATE ISSUED ,i i /��r. ��a.-.Dom. , (Complete in Triplicate) Application is here y 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.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. qI'' Job Address 291 Warrou ° - City TAthrOP_ Lot Size 2 acres PM Owner's Name Jots Aurelio .Address 291-TA?arrea_Av_e.._ I.athro Phone 982-4833 ,- T1290-Vallejo Ct. ContractorVaT10 o CofaBt: I11C ,address French Camp, CA 95231 License No. 479838 TPhone 982-5661 .TYPE OF WELL/PUMP; �� jj NEW WELL ❑ WELL REPLACE MENT-©--GESTRU&TION-1=1---T----�- f 4PUMP INSTALLATION LJ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TtNK SEWER LINES DISPOSAL FLD. PROP. LINE FOtjNBAION AGRICULTURE WELL OTHER WELL PITSISUMPS I j INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUC710N SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well,Excavation Dia. of Well Casing ❑ Domestic/Private -❑ Gravel Pack ❑ Tracy f—T-ypa�,of Casing Specifications I. t ❑ Public n Other ❑ Delta Depth of Grout Sea! Type of Grout 6 I I Irrigation _Approx. Depth l I Eastern Su ale S I Installed by Repair Work Done ❑ Type of Pump H.P. : __ State Work Done_ Well Destruction C Well Diameter Sealing Matenallltop 50'1 f Depth Filler Material_03elow 501) t N TYPE OF SEPTIC WORK: NEW INSTALLATION la REPAIR/ADDITION {.l DESTRUCTIOhWX fNo septic system permitted if public sewer is i available within 200 feet.) ~ Installation will serve: ResidencA Commercial_ Other `" p Number of living units:) Number of bedrooms ri Character of soil to a deptha of 3 feet: i Water table depth t3 SEPTIC TANK 1% Type/Mfg Cement Capacity unkaTT No. Compartments PKG. TREATMENT PLT, ❑ i Method of.Disposal i 4 Distance to nearest: Well Foundation 'Property Line 1 LEACHING LINE ❑ No. & Length of lines i Total length/size FILTER BED ❑ Distance to nearest: Well Foundation . Property Line SEEPAGE PITS l I Depth Size { Number ! I SUMPS ❑ :Distance to nearest: Well Foundatiln P_roperty_Line b 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 r 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 applicaril mLlst call for all`required inspections. Complete drawing on reverse side. Estimator Date:Signed X Title_: Date: FO PARTMENT USE ONLY - Application Accepted by ,;R M-��.Dat! Area 13 Sti Pit or Grout Inspection by �I Dated I V i '�Finl Irispection`by / d6 Da Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835=6385 Applicant - Return all copies to: Environmental Health Parmit/Services.1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 I! FEE INFO AMOUNT DUE AMOUNT REMITTED CASH CK 49 RECEIVED BY PATE PERMIITX T,'(N`O. + EH 13-24{qEV.I/n 51 rQ� TM 7^ ' EH t42a 1J 6 l/ ,['7 / c'L r ,