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�•— - •: APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 3'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 Ordinance No. 549 fors wage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address ZSR �) Q S' d City Lot Size PM ,p f Owner's Name f1�o e.-C_ 36a fI11 Address Phone Contractor as- f'1 P14 Address_ �P(Jf ICOr/ d4 d gk License No. 6 v Phone S 7 1 TYPE OF WELL/PUMP: NEW WELL. WELL REPLACEMENT.. DESTRUCTION PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ ; DISTANCE T ,NEAREST: SEPTIC TANK �Ut SEWER LINES �a� DISPOSAL FLD. PROP. LINE t.V FOUNDATION ?�L AGRICULTURE WELL OTHER WELL_-AQ!_ PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial t-5-Open-Bottom—P-Manteca—-0-Manteca—Dia-of Well-Excavation- ----- Dia:of-Well-Gasing S� EA Domestic/Private WGravel Pack ❑ Tracy Type of Casing ,� ,Pe Specifications F Public D Other ❑ Delta Depth of Grout Seal r ab f Type of Grout F n_ I I Irrigation _-Approx. Depth I 1 Eastern Surface Seal Installed by Repair Work Done ❑? Type of Pump - H.P. , I State Work Done Weil Destruction ' Well Diameter. # Sealing Material (top 50') ( � 1 Depth .7Eo2 Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I1 REPAIR/ADDITION l I DESTRUCTION l I Wo septic system permitted it public sewer is " available within 200 feet.) Installation will serve:! Residence_ Commercial Other f" - - 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 ti Distance to nearest: Well Z Foundation Property Line V1 j t LEACHING LINE ❑ No. & Length of lines •- Total length/size FILTER BED 0 Distance to nearest: Well Foundation Property Line •� U SEEPAGE PITS i I Depth Size Number ' SUMPS ❑ Distance to nearest: We11 Foundation Property Line DISPOSAL PONDS 'ID 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 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-contractingTsignature 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 cont pensa- j tion laws of Cncaia-"� 11 The appiican m t call for all require spectio omplate drawi on reverse side. F Signeditle: Date: d FOR DEPARTME T USE ONLY Application Accepted by _ Date �1� Area �+ Pit or Grout Inspection by Date�— Final Inspection by Date 2 26 7j '75 (o7 El Z6Z` Additional Comments: -t _� ElStk 466-6781 El Lodi 369-3 21 F-1Manteca823-7104 ❑ Tracy 835-6385 Applicant Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box zutrttk`; CA 952 1Wr�h AZ INFOK AMOUNT DUE AMOUNT REMITTED GASH RECEIVED BY DATE PER�M]IiT'NO.. +.EH 13-24{REV.r/n 51 ^ 1 �4 1In 1-011 Jq1 x+13 ,� EH 14-28 l {.�