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APPLICATION FOR PERMIT 1.J SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELFON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Applicaon is /or in all the work .This application is made nticcompliance writh San Joaquin County ordinaade to the San Joaquin lnce Nto.5491 r sewage or Healh District for a Permit 1862 for cwellldpump end the Rules and IR Regulations of the San Joaquin Local Health District. !p Job Address 1V3 V® �® �` Cin'slf�clt:;,- Lot Size FM Q > ? -- Owner's Name 1rJ+Llr / �rt�Gddress A�� Phone Contractor 5�" Atldress � License No.�Phone �4 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT El DESTRUCTION ❑ PUMP INSTALLATION 11 SYSTEM REPAIR ElOTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHEK WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS :Dia. ofll Casing❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavationons❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing out— M Public F1 Other n Delta Depth of Grout Seal I Irrigation —Approx. Depth I I Eastern Surface Seal Installed by_ - 1 State Work Done Repair Work Done ❑ Type of Pump H.P. Well Destruction C3Well Diameter Sealing Material (top 501 Depth Filler Material 18elow 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I.1 REPAIR/ADDITION DESTRUCTION I i aNailabPelwithine200 f eti��ed if public sewer is L Installation will serve: Residence_ Commercial Other (1 Number of living units: _ Number of bedrooms gyt•,t� - Water table depth Character of soil to a depth of 3 feet: a No. Compartments SEPTIC TANK 19 Type/Mfg Capacity b ethod of Disposal PKG. TREATMENT PLT. ❑ D"tstance to nearest: Well Foundation Propert Line LEACHING LINE Cr No. & Length of lin s ital length/size FILTER BED ❑ Distance to nearest: Well Ibc) oundation « Property Line SEEPAGE PITS I I Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Lim 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." G The apRKea4e must call for all required inspections. Complete drawing on reverse side. Signed �H y✓ - �___ Title: CT�C�-e-�L Date: SE ONLY•a;\,n Date Area Z Application Accepted by �- p�Pit or Grout Inspection by Date Final Inspection by Additional Comments: ❑ Stk 466-6761 ❑ Lodi 369-3621 ❑ Manteca 623-7104 ❑Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 20D9, Stk., CA 95201 FEEOMWU1,,1,T CK RECEIVED By DATE n-M, INR//ESM/ITTED CA,(SH1 �(p EH 11211REV.pin Sp U(/ WUl � EH 1425