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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRRr( 1601 E. HAZELTON AVE., STOCKTON, CA 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 i r sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin made in compliance with San Joaquin County Ordinance No.549 fo Local Health District. Job Address 18665 S J51C Rodd _ City Mantas Lot Size 54 Ararc PM Owner's Name ISI $ Sonke _1janIll__ Address 1 R66r, S T--1St—nDC0d Phone Contractor Martin ru,y & Supply Address 5 Reed Road License No.360-858 Phone 70 394 TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION IR SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK 100' SEWER LINES 100'+ DISPOSAL FLO.10.01. PROP. LINE ML FOUNDATION 20' AGRICULTURE WELLNOM OTHER WELL % PITS/SUMPS None INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Step-1 Specifications g Domestic/Private Gravel Pack ❑Tracy Type of Casing 50 Type of Grout $ant rite (1 n Public Other 171 Delta Depth of Grout Seal � I I Irrigation —Approx. Depth 1 1 Eastern Surface Seal Installed by - ftN Repair Work Done ❑ Type of Pump gullet-- H.P. 3— State Work Done_ rA Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE-OF WORK: NEW INSTALLATION I1 REI TION I I DESTRUCTION I I (Nailabptic s temin permitted if public sewer is 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 Method of Disposal PKG. TREATMENT PLT. ❑ 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 I I Depth Size-- Number SUMPS Ll 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 D3trict. - 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 applicanj st call for all requir insp ti ns. Complete awing on se side. I /� Signed Title: 1 J Ff�k A u" ' �' Date: FO PAR E USE ONLY G 1 _ Date rea Application Accepted by Date o � '�,r� '� Final I spection by Pi[or Grout Inspection by a� Date Additional Comments: ( /� ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-663385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2(109, Stk., CA 95201 FEE - — CK RECEIVED BY DATE PERMIT NO. AMOUNT DUE AMOUNT REMITTED ASH INFO `� EH 1324 IREV,rix sl `'�� yd�� X04 EH 1425 S-7— 91