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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1"YEAR FROM DATE ISSUED APN 06�316 —6 (Complete in Triplicate) � lgr 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 Ordinance No.549 for """s�ffe"""wage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. �j-7O / L/6��f� C� Job Address �/ ' v/ City & % "'S Lot Size / 0 �C PM Owner's NameEA ` �* Address 3 1 ( Phone Q ` wpovelf 1 J661 i License No. '1"2 'a rS Phone 'q� Contractor >E 4f S Address TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEP,ITIC TANK SEWER LINES DISPOSAL FLD. ,PROP. LINE SOD V FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS O INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 6 1 ❑ Industrial ❑ tJ•pen Bottom ❑ Manteca Dia. of Well Excavation 10 Dia. of Well Casing lOVC �[ Domestic/Private Graveli. Pack ❑ 'Specifications - Type of Casing M Public - ❑ OFther (-1 Delta Depth of Grout Seal _r'?- _ Type of Grout C'-e I 1 Irrigation 3 "Approx. Depth l I Eastern Surface Seal Installed by Oa✓r"4_T*r,,__ - ' Repair Work Done L3 Typi of Pump 6— H.P. 3 State Work Done Well Destruction ❑ Well Diameter L a Sealing Material Itop 50'1 CPA ,�. Depth Filler Material I Below 50'I �- 4 TYPE-OF SEPTIC WORK: NEW INSTALLATION l I REPAIR/ADDITION 13 DESTRUCTION I } {No septic system permitted if public sewer is- o available within 200 feet:)- llation will serve:_Residence_ Commercial_ Other ^s" Number o i mss: Numher of bedrooms~ ._ Character of soil to a depth o Water table depth a E„ SEPTIC TANK ❑ 'Type/Mfg Capacity No. Compartments t s'PKG. TREATMENT PLT. ❑ I�� Method of Disposal {tee .Distance to nearest: Well Foundatlo Property Line Total len th/size .LEACHING LINE ❑ No. & Length of lines g FILTER BED ., ❑ Distance to nearest: Well Foundation . Property Line SEEPAGE PITS I l Depth Size Number "SUMPS ❑ `Distance to nearest: Well Foundation Property Line DISPOSAL PONDS LI ~I 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 l employ any person in such rnanner 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 applicants must call for all!required inspections. Complete drawing on reverse side. oe Signed X_ Title: OG4. Date: FOR DEPARTMENT USE ONLY �_� Application Accepted by Date_ �� Area Pit or Grout Inspection by;Vat%Kk Date/ `� Final Inspection by y Data Additional Comments: 11. ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box2009, Stk., CA 95201 N 1� FEE AMOUNT DUE AMOUNT REMITTED CK H RECEIVED BY DATE PERMIT'N . INFD r + EH 13-24 1pEV.t 51 0 EH 14-2a