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APPLICATION•FOR PERMIT SAN JOAQUIN;LOCAL'�HEALTH DISTRICT ' 1601 E. HAZEL T ON:AVE., STOC'KTON, CA M Telephone (209) 466-6761 Ft s:' tr ;'f 1e 1>f ,PERMIT EXPIRES 1 -YEAlk,FROM DATE.ISSU.ED,1v;p 11 , (Complete•in Triplicate)(e :'vsf.V.� �: ... ,,;, ,c -''":'. r .,•vii Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein deg! ed: This application is .made in coinpliance with San Joaquin-County Ordinance No 549 for.sevvageYor No:;18fi2 for well/pumpand the,Rules and.-Regue San.Joaqqin Local Health District,, s isi . sr?:r• . n ., a 's F' � CQ SCF[ rte) r 1 r Y li? f �- # .rii`_i0 'R,t+� '31F S �"�� y� J� 4 Job Address - �`�' City 1�+ of Size, . .PM 4 Owner's Name Address F Phone µ 4= �y Contractor's Name License No.- ' Phone. a .TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION ❑. - PUMP INSTALLATf N SYSTEM REPAIR O OTHER ❑ , DISTANCE',TO NEAREST: SEPTIC.TANK _ SEWER LINES DISPO_SA PROP. LINE FOUNDATION AGRICULTURE WELL. OTHER WEL - PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIF19JI 2 .❑ Indo I ❑ Open ttom ❑ Manteca Dia.-of Weil Excavation.' Dia. ofWellCasing (� omestic/Private avel Pack ❑ Tracy Type of Casing ' � Speci[cationsr ❑ Public; ❑ Other 9 a ❑ Delta Depth of Grout Seal TypeofGrout LJ Irrigation �4pprox. De th astern ` Surfac al Installed by. ` A ' /� Repair Work Done ❑ Type of Pump H.P. State Work Done k Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth -Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION`❑ DESTRUCTION ❑ (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 ' M Character of soil to a depth of 3 feet:' "' ` }` Water table depth SEPTIC TANK ❑ ;Type/Mfg Capacity �No. Compartments . f `PKG. TREATMENT'PLT. ❑ Method of Disposal r i - 'Distance to nearest:- Well' : Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total.length/size .FILTER BED ❑ .Distance to nearest: -Well "Foundation *4- _Property Line Y. ' PS , PITS CI 'Depth 'Sizei `Number ` SEEPAGE -14 ;SUM ` o K: . . '° �Pr (. t . • 'SUMPS n ;❑ `Distance tb nearest r well Foundation Pro Line tine ` s t ,r DISPOSAL PONDS ❑ _. .• t' a-' � ! Y'" ` • ;1 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 andregulations of the San Joaquin Local Health District. 4 ! 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 followi09a. at in the performance o the work forwhich this permit is issued, I shall employ persons subject to workman's compensa- tion laws ofCalifokThe appl can red ' I n o lets drawing on rse side, FF V I Signed r. Title- 16 •" `moi Date: FOR DEPA N USE ONLY / J Application Accepted by Date ArqA r Pit or Grout Inspection by' / ' I W Date Final Inspection by Y Date ""r`.;�"'- ,�•4•. 9 ....,:--per.�--�... . •;� - .� �'.--,,. Additional Comments: - -;❑ Stk 466-6781 ' (D Lodi-369-3621•) - ,D Mantece823-71104'3-3-Tra-by--835-6385��-- — ( - `-� +� --:•:^ - -*--� Applicant Raturn all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009,'Stk., CA 95201 , i_. . � 1- ,.. .i "-. _.i_._,i_ --� -_-jam_ _ - - M •.< .. 4 ' FEE'" __1AMOUNT DUE j AMOUNT REMITTED t CASH RECEIVE4 BYCK 0 ' DATE' PERMIT`NO. INFO +�EH 13.24IREV.10.1331 LLrl7 - { q L. .- j: EH 14-28