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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 I PERMIT EXPIRES TYEAR 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 Ordin nce No. 549 for wage or No. 1862 for well/Pu and the Rules and Regulations of the San Joaquin Local Health District. 12 Jr, G 7� a O �,°>f `° 11 1 yAI' Job Address O 1 e Cit Lot size ctc�e- PM Owner's Name 0J Q ddress t2 2S 1 �A nN n r\-.f) G Phone Contractor Q L _ t h Address T •�_ @I- �'1�- 3 rt� - License No.t -�q3Phone 69`-77 TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ti SYSTEM REPAIR 0N.- OTHER ❑ DISTANCE"TO NEAREST: SEPTIC TANK .•SEWER LINES 1r1'OSAL 4 FOUNDATION -AGRICULTURE WELL OTHER WELL PITS/SUMPS f� r INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial VOpen Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing $' Y-Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing L� Specifications �n - F 1 Public f_1 Other f Delta Depth of Grout Seal' `r. Typ f Grout[_ e_me+ti I Irrigation _-Approx. Depth l I Eastern Surface Seal installed by f A ' r �f IA Repair Work Done ❑ Type of Pump � H.P.Z State Work-Done_ y Well Destruction ❑ Well Diameter Sealing Material (top 501 �J Depth Filter Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I] REPAIR/ADDITION l I DESTRUCTION l 1 INo septic system permitted if public sewer is w available within 200 feet.) Installation will serve: Residence_ Commercial_ Other i. Number of living units: Number of bedrooms 7 Chaiacter 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 i LEACHING LINE ❑ No. & Length of lines Total lengthlsize FILTER BED ❑ Distance to nearest: Well Foundation Property Line 1 . f SEEPAGE PITS I 1 Depth Size _ Number SUMPS 0 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 Do-strict. 'i 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 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 applicant must call for all requiredi pections. Complete drawing on reverse side. Sigped X _ A jvvt AA9-— Title: < - - Date: , r FOR DEPARTMENT USE ONLY ,�,� y—all r� Area Application Accepted by _ Date Pit or Grout inspection by DateFina] Inspection by,Jl� Datert� Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 1123-7104 ❑ 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'._ AMOUNT REMITTED. - CASHRECEIVED BY_,_ -DATE;- - PERMIT.NO.9,9 - — — -� INFO "" +-EH13-24(REV.t 1 N 5) 1 Y- EH t4-2B