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APPLICATION FOR PERMIT SAN JOAQUIMLOCArL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 li y PERMIT EXPIRES 1'YEAR FROM DATE ISSUED I ;� (Complete in Triplicate) l h Application is he+eby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is or No. 16b2 for welllpump and the Rules and Regulations of the.San Joaquin made in compliance with San Joaquin County Ordinance No. 549 for sewage t Local Health District. 'I Job Address So, 4JU-4 Is City SJ�KFaN Lot Size PM Owner's Name IN Address _5 �� Phone qg Ii fG S ContractorsZ5 License No. -57Z2-68 Phone 'YYP, -13y7 TYPE OF WELLIPUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR © OTHERy�Z � Tasr a,t DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP- LINE _-..�51� 1. FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 11 Industrial ❑ Open Bottom ❑ Manteca . Dia. of Well Excavation I ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing 0 Public ❑ Other C7 Delta Depth of Grout Sealtf 1 1 Irrigation _.-Approx. Depth l I Eastern Surface Seal installed by Repair Work Done ❑ Type of Pump H.P. State Work Done !.Im T Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 541 TYPE OF SEPTIC WORK: NEW INSTALLATION { I REPAIR/ADDITION l 1 DESTRUCTION l I (No septic system permitted if publicisewer is t available within 200 feet.) Installation will serve: Residence_ Commercial— Other C Number of living units: Number of bedrooms i J Gharacter of sail to a depth of 3 feet: Water table depth 0 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 4! FILTER BED ❑ Distance to nearest: Well Foundation Property Line r SEEPAGE PITS I I Depth Size Number , Il SUMPS L� Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ " I hereby cartify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and i 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 employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature f 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 t call for aII re wired inspections. Complete drawing on reverse side. „ �y Signed X Title: a-0�`• ,G-0L400,L S,-F Date: iqFOR DEPARTMENT USE ONLY 4 Application Accepted by Date /(rL� - Area a I" cPr7��-='/` /ocd..� 5ee Da et /2- C4 �r Pit or Grout Inspection by Date Final Inspection by K CCP � ,q.i..ra.a-� Q'C �✓�r� Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/ServiceF s 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 85201 MK 4 i FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT'NO. i INFO +.EH13-24(REV.FiK5i 1,0 - EH 14-26 .i