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Lr y w APPLICATION FOR PERMIT ( fn J SAN JOAQUiN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT N0. Telephone (209) 466-6781 .PERMIT EXPIRES 1 YEAR FROM DATE ISSUED DATE ISSUED (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install in described. This application is made in the work here compliance with San Joaquin County Ordinance No. 549 for seWein and the Rules and Regulations of the San Joaquin Local Health District, wage or No. I8work for pump Job Address—.1 O + t�j('7'p,Q �'P 1.An 55ubdivision Name Owner's Name Lel _ t"7 Li VF2 Address ` Contractor's Name 50A1 � �71 5- a phone —SWei \ �li�3 �Il _License No. �._,... c_ —. --- Phone � TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ \�� ,PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK _ EQI J" SEWER LINES DISPOSAL FED, Q — —�!Q!�-� 7` � '4--PROP.DPLINE _ �Q FOUNDATION' fJ°TR AGRICULTURE WELL OTHER WELL pITSl5UMP5 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS � L� Industrial N Open BottomManteca ❑ Y Dia. of Well Dia. of Well Excavation Tra ❑ Domestic/Private ❑ Gravel Pack cIJ �I ❑ Casing ❑ Public EJ Other ❑ Delta LX Irrigation Type of Casing 6 /6�e e�Approx, F] Eastern ❑ Cathodic Protection Depth Specifications ❑Geophysical Depth of Grout Seal __4Z LJ Other Type of Grout i Surface Seal Installed by r I Repair Work Done Type of Pump H.P. State Work Done Well Destruction Lf Well Diameter Sealing Material (top 50') Depth Filler Material (Below 501) FM ga TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ (No septic tank or seepage pit permit f bhic er is 1 . ti Installation will serve: Residence _ Commercial Other available within 200 f ) Number of living units: Number of bedrooms Lot size Character of sail to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. [) Type/Mfg Capacity Method of Disposal ,. SEWAGE SYSTEM ❑ Distance to nearest: Well Foundation DESTRUCTION Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS Depth Size Number SUMPS L Distance to nearest: Well Foundation Property Line DISPOSAL PONDS h 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 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 compensation laws of California." The applican must call 'or 11 equed inspections. Complete drawing on reverse side. Signed X Title: Date: F DEPART NT USE ONLY f�- T Application Accepted by Opp(Area ❑ Stk 466-6781 Additional 'Comments: Lodi 369-3621 Pit or Grout Inspection by Date L__I Manteca 823-7104 Final Inspection by Date0 Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Selyces 601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO BASE AMOUNT DUE VVr AMOUNT REMITTED RECEIVED BY DATE PERMIT N0. EH 13-24 REV. 10/82 �XCNt� 10/82 500 14-26