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�. APPLICATION FOR PERMIT `t SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA f Telephone (209) 466-6781 PERMIT EXPIRES TYEAR 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 Ordi ce No. 9 for sgwege or No. 1862 for welllpump and the Rules and Regulations of the San Joaquin Local Health District. 3 /_��. t Jab Address (�I S /a City of Size PM jj /✓ Owner's Name Address - 44c Cl?hone 1�+ Contractor Q5 Address laS7.z5 T - License No. oz�/C?�'/ Phone t TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTIONSX' PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PIT5ISUMPS f INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom (I Manteca Dia. of Well Excavation Dia. of Well Casing I r Q Domestic/Private ❑ Gravel Pack ElTracy Type of Casing Specifications I`l Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ---- 1 1 Irrigation Approx. Depth I I Eastern Surface Seal Installed by - I _.- r I Repair Work Done [2 Type of Pump H.P. Mate FE� �Well Destruction Well Diameter lam[ _ Sealing Material Ito�.f�9'i Depth I t Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW 1N5`TALLAT{ON !.I REPAIRIADDITION l I DESTRUCTION l 1 aNailabpelwisystem thin 200 feetft4ed if public sewer is installation will serve: Residence Commercial_ Other Number of living units: Number of bedrooms f Character of soil to a depth of 3 feet: Water table depth r SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ 1 Method of Disposal i Distance to nearest: Well Foundation Property Line b _ Total len th/size LEACHING LINE ❑ No. & Length of lines g I FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I 1 Depth I Size _ Number SUMPS L1 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 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 Diltrict. Home owner or licensed agent's signature certifies the following: '9 certify that in the performance of the work for which this permit is issued, f 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 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." 1 The applicant st call for all requir inspections. Complete drawing o se side. Signed X itle: Date: R D RT NT USE ONLY Application Accepted by Date Area � Pit or Grout Inspection by Date Final Inspection by '""ate Additional Comments: 0 e r Ql '4` -7 12,G- q ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 1 FEE AMOUNT DUE AMOUNT REMITTED K RECEIVEI!G DATE PERMIT'NO. (INFO /�^�� + EH 1324(REV.I/n 5) /i�C— V-a'" LL � � A'� '��_� � EH 14-28 IWN'