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r. P, ' APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E:_HAZESTON rAVE., STOCKTON, CA k 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 made in compliance with San Joaquin County Ordinan o.549 for wage'or862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. -07Z/® �Y, dc Job Address City Lot Size PM Owner's N e - ?Dress Phone �j "� Contractor ) r License No. Phone TYPEiOF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ ' 1 OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES _DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial Ll Open Bottom ❑ Manteca t Dia. of Well Excavation Dia. of Well Casing C•Y6orr estic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 1-1 Public ❑ Other LJDelta 1 Depth of Grout Seal Type of Grout ❑ Irrigation wwf r . pep El Pastern Surface Seal Installed by Repair'Work Done E� Type of Pump' H.P. f State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') I Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION El., DESTRUCTION El (No septic system permitted if public sewer is I k available within 200 feet.) 4 installation will serve: Residence____ Commercial— Other Number of living units: Number of bedrooms 1 Character of soil to a depth of 3 feet: Water fable depth SEPTIC TANK ❑ Type/Mfg 'Capacity No. Compartments PKG. TREATMENT PLT. El � —,,- Method of Disposal i Distance to nearest: Well Foundation Property Line * LEACAING LINE ❑ No. & Length of lines Y " Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size t Number SUMPS ❑ Distance to nearest: Well Foundatlon Property Line -- DISPOSAL PONDS ❑ ' I hereby certify that I have ared this application and that the work will be done in accordance with San Joaquin county ordinances; state laws, and rules and regulations a San oaquin Local Health District, I Home owner or lie sed agent's ignature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any pe in such man r as to became subj workman's compensation laws of California."Contractor's hiring or sub contracting signature , Certifies the f owing:"I certi at in a the work for which this permit is issued,I shall employ persons subject to workman's compensa- tion laves of allfornia." The appli nt all re re mpi a drawing on v r de J\ k 1 SignedS Title: r Date: s ZFOPARTMENT USE ONLY Application Accepted b Date Area i Pit or rout Inspection by ate Final Inspection`by _ Date 2"�C� Additional Comments: ❑ Stk-;-466-6781 ❑ Lodi' 369-3621 ❑ Manteca 823-7104 ❑ Tracy- 835-638.5 Applicant�fleturn all copies to: Environmental Health Permit/Services 1601 E:Hazelton Ave., P.O. Box 2009, Stk., CA 95201 I FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PER 9NO.. v r� INFO CASH �+ EH 13-24IREV.I/95) ='5 EH 14-28 i