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APPLICATION FOR PERMIT A SAN JOAQUIN LOCAL HEALTH DISTRICT r 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 t� PERMIT EXPIRES S YEAR FROM DATE ISSUED 0 ! (Complete in Triplicate) ZS 11-04 / V"71 vzl O q 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 O inance No.�Ufosewageor No. 1862 for weli/pump and the Rules and Regulations of the San Joaquin Local Health District. q� X7//,``/ Q G�' 1, Job Address�P.ALY T zt'' I v�� City Lot Size i ( PM Owner's Name �^ Address Phone Contractor �C �1J `lsr+dl7fess r F-- t( 7 License No, hone � TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION DC110 a IO- PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER�#jam' kb240bl!� DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE 60 T, S fX� FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS f jf DI INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS C] Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 9 t Il Domestic I Private ❑ Gravel t'Pack ❑ Tracy Type of Casing Speeitic, r FI Public n Other 1 ❑ Delta Depth of Grout Seal T-yFe-of 6ratit 4 �— I I Irrigation _Approx• Depth I I Eastern Surface Seal Installed by IAJILI— Repair Work done LJ Type of Pump H.P. State Work Done_� ?LWm �I F- r r Well Destruction ElWell Diameter Sealing Material Stop 50'I _ Depth Filler Material (Below 50') — t TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION i I DESTRUCTION i I (No septic system permitted if public sewer is JZ I available within 200 feet.I Installation will serve: Residence, Commercial— Other 0 i Number of living units: Number of bedrooms ! Character of soil to a depth of 3 fe'et: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property line LEACHING LINE ❑ No. Length of lines Total length/size r FILTER BED ❑ Distance to nearest: Well Foundation Property Line + I �1 SEEPAGE PITS I I Depth Size Number a SUMPS ❑ Distance to nearest. Well Foundation Property Line DISPOSAL PONDS ❑ f 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, !shall not ` employ any person in such manner as to become subject to workman's compensation laws of California.'"Contractors hiring or sub-contracting signature certifies the following: "I certify that i the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa tion laws of Cali nla." Theapplicant for red inspections. Complete drawing on reverse side. Signed X Title: Date: FOR PARTMENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection by Date Final inspection by � Date Additional Comments: ' 0 Stk 466-6781 ❑ Lodi 369-3621 © Manteca 823-7144 ❑ 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 CK II ♦. RECEIVED BY DATE PqERMIT N O . EH 1321(RVsl INFO 0 G EH 14-28 v� o � IV