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.. - 1 APPLICATION FOR PERMIT �Q 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 or No. 1862 for well/.pump and the Roles and Regulations of_the San Joaquin made in compliance with San Joaquin County Ordinance No.549 for sewage Local Health District. C. Job Address Ci �c ��-Lot Size � fl PM - iu -[ O C� Address 7��-� /-4 ['-Pa)Lt o 1�- Phone Owner's Name Contractor�� c'as't Address XZ3 7 �` License No. Phone TYPE OF WELL/PUMP: NEW WELLA WELL REPLACEMENT LlDESTRUCTION El PUMP INSTALLATIONS SYSTEM REPAIR. ] OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD, PROP. LINE en-Q FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS � L1 Industrial Ll Open Bottom El Manteca Dia. of Well Excavation 't Dia. of Well Casing `4 Domestic/Private )Z Gravel Pack' ❑ Tracy Type of Casing s'Te 4V Specifications Sx ❑ Public ❑ Other I ❑ Delta Depth of Grout Seal CZ) Type of Grout ❑ Irrigation '77ehZ�-Approx. Depth ❑ Eastern Surface Seal Installed by T q Repair Work Done ❑ Type of Pump DuL H.P. State Work Done i Well Destruction ❑ Well Diameter Sealing Material (top 50') QmL) Depth Filler Material iBelow 501 #-4,4- ge. E OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) a Installation wi Residence Commercial_ Other Number of living units ber of bedrooms Character of soil to a depth of 3 fee - Water table depth �� nc:-th SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. Ell: Method of Disposal .. Distance to nearest: Well ! Foun' Property Line j I LEACHING LINEElNor{&Length of lines Total lengt r FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ 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 l rules and regulations of the San Joaquin Local Health District. F 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 It 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 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." h The applicant must call for all r quired inspections. Complete drawing on reverse side. I Date: r Signed X 26& A' — F Title: FOf1l DEP RTMENT U�ONLY I Application Accepted by Date 4"4- ^r(#v Area t Pit or Grout spection by Date &""� Final Inspection by 4 Additional Comments: ❑ Stk 468-8781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 ! Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE.j AMOUNT REMITTED RECEIVED BY DATE PERMIT-NO. � - + EH1 -2CV. 1 1p� EH 14266