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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 OC)- a PERMIT EXPIRES 'I YEAR FROM DATE ISSUED S,e�N J0 , 19e4 (((JJJ {Complete in Triplicate} �FgLpU),V Woaquin Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein descrition is made in compliance with San Joaquin County Ordinance No.549 for se age or No. 1862 for well/pump and the Rules and Regulations. Local Health District. f °ISS' 6d WOOr� ,t ,�al•/Z/9X32L 4a4t T--is-,y4 Job Address �L.7,Lrf�' � `" City Lot Size 'f PM Owner's Name . C�-l��t. �J��CICf�J(C (� Address 20461-5-Of-AU4 hone J'Z t5-M7 1 Contractor's Name License No. 62—f© Phone TYPE OF WELL/PUMP: V NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK ICL, I SEWER LINES DISPOSAL FLO. AM) PROP, LINE FOUNDATION , AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom anteca Dia. of Well Excavation Dia. of Well Casing f� ltomestic/Private 4Aravel Pack 0 Tracy Type of Casing A 0Plt.,__ Specifications 12 ❑ Public ElOther ❑ Delta Depth of Grout Seal x'56 0 Typ f Grout llaktale&5 ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 O Depth Filler Material (Below 501) TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer Is available within 200 feet.) Installation will serve: Residence_ Commercial— Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: 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 FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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 fallowing: "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."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 applicapt rr just call for all reqled in.Vittions. Complete drawing ov-reversq side Signed tle: Date: 119A &FOIDD1,EPARTMENT 5E ONLY / {�Application Accepted by Date/9f / � AreaPit or Grout Inspection by e Final Inspection by—_WIA Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 8356385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CAS RECEIVED BY DATE PERMIT'NO. + EH 1324 MEV.101831 EH 1426