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I , •_ - APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA I 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 Jaa urn County Ordinance N 549 wage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. 'f, ��' � d Job Address �L�,.r?t„c •� 010 1? W6ize _ f� 44-l'ILS' PM Owner's Name it R4�41 Address H r r Phone — ! • / Contractor 6,K/JLAddress �! �S L":cense No.S�tSTS�7 � Phone TYPE OF WELL/PUMP: NEW WEL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK �� r SEWER LINES �({�� /' DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELI„��OTHER WELL PETS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation /9� Dia. of Well Casing C*LpQmestic/Private Gravel Pack ❑ Tracy Type of Casinge�(.f�� —___ Specifications Q� ❑ Public 171Oth7 ❑ Delta Depth of Grout Seal /L�2/ (Type of Grout,/4�— tC7 I I IrricJation 1pprox. Depth I 1 Eastern Surface Seal Installed bye/, � .rrL/ruT Repair Work Done Ll !Type of Pump!!! H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing,.Material (top 501 I Depth Filler Material (Below 501 _ /f TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I 1 DESTRUCTION I 1 (No septic system permitted if public sewer is �f 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 vvv SEPTIC TANK ❑ Type/Mfg} Capacity No. Compartments r PKG. TREATMENT PLT. ❑ Method of Disposal y Distance to nearest: Well Foundation Property Line r LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line { SEEPAGE PITS [ I Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line f� _ DISPOSAL PONDS ❑ { Y l hereby certify that t have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and f � 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 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 ust call for alf requir i pections. Complete drawing on reverse s•de. Signed X / l Title: ,Lj_f �Q Date:�3 4 f0 DEPARTMENT USE ONLY g Application Accepted by Date 'ZZ Area Pit or Grout Inspection by c� Date Final Inspe tion by Date Additional Comments: —a_. / G � ❑ Stk .466-6751 ❑ Lodi 369-3621 ❑ Manteca 523-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, tk., CA 01 f �3 �' 9,LT 116FEE r rJ INFO AMOUNT DUE AMOUNT REMITTED,, CKJlr SH RECEI ED BY DATE PERMIT•NO. +.EH14-24 4REV.r/ns7 M D 3 g -A1 �_ : EH 14-28 l [[ G E , l.1(� 1�.�] l! V`l