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h k 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 (Complete in Triplicate) � : aquin Local Health District for a permit to construct and/or install the work herein described. This application is Application is he+eby made to the San Jo or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin made in compliance with San Joaquin County Ordinance No.549 for sewage Local Health District. r� � , � ,r Lot Size PM Job Address cot �7 tC/t1 City +/i[.c W Address ��_ Phone Owner's Name "_3 &96&96� =mss Contractor 61-4 Address F1:44�6- 9 License bio. Phone_ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION C] SYSTEM REPAIR � OTHER ❑ DISPOSAL FLD. PROP- LINE DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES --•�"�_ FOUNDATION AGRICULTURE WELL ' `OTHER WELL PITS/SUMPS I INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial 13 Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Specifications Domestic/Private ❑ Gravel Packs l"1 Public Other ❑ Tracy Type of Casing ❑ Delta Depth of Grout Seal Type of Grout I I Irrigation —,Approx. Depth i I Eastern FSurface Seal Installed by Repair Work Done Type of Pump H.P. f.w�� + State Work Done Well Destruction ❑ Well Diameter Sealing Material {top 50'1 Depth Filler Material Melow 50')" —� TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I 1 DESTRUCTION I 1 iNo septic system permitted it publicseweris l available within 200 feet.) Installation will serve: Residence�.—� Commercial— Other Number of living units: Number of bedrooms Water table depth Character of soil to a depth of 3 feet:" SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG fTREATMENT PLT. ❑ A. Y Method of Disposal Distance to nearest: "Well Foundation Property Line ^ I LEACHING LINE L-1 No. & Length of lines Total length/size • a - FILTER BED ❑ Distance to nearest: Well y Foundation Property Line ~ i + SEEPAGE PITS l I Depth Ir Size Number SUMPS Cl Distance td nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 11 ~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, an 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, 1 shall not employ any person in such`manner as t"rib"stoma 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." I The applica all for all required inspections. Complete drawing on to side. ' r � Title: s0 Date: Signed X FR DEPARTMENT USE ONLY t � � Area Application Accepted by Date Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: LJStk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-71D4 ❑ 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) CACK H RECEIVED BY OATS PERMIT'NO. INFO S _ i a / +.EH13-24iREV.+/risi EH 14-2e --