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NIM APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE i ON 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 7a,iP n com;;iian,c with San Joaquin County OnJnlan e No.b49!of;.ewa!?e or Nu. 1RG2 for v.reupump and the Rules and Regulations of the San Joaquin Loc,,,' Healm Distncr City E41e&Lot Size PM Job Address ! U U el ^ J Owner's Name Address Phone C�,J AZ-- W-3 -9 ,(f License No. /Y J 3 -9k Phone 9 Contractor� re s TYPE cl WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION E3 PUMP INSTALLATION a SYSTEM REPAIR ❑ OTHER O DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS t INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS El Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack Cl Tracy Type of Casing Specifications 1.1 Public n Other Pi Delta Depth of Grout Seal Type of Grout Irrigation —Approx. Depth 1 ! Eastern Surface Seal Installed by 7 14 Repair Work Done ❑ Type of Pump H.P. State Work Done_ Well Destruction L7 Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION I-, REPAIR/ADDITION I I DESTRU TION f ' o septic system pefmitted if publjc sewer is � avail I withi 200 feel.) zfu�f�- 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/0 0 No. Compartments PKG. TREATMENT PLT.F] Distance of�D/is�o�al Distance to nearest: Well jv -r e Foundation Property Line 4 LEACHING LINE ❑ No. & Length of lines 2 ' -Tggtal length/size FILTER BED 11Distance to nearest: Well U Foundation Property Line SEEPAGE PITS I I Depth �� Size Z Number SUMPS 11 Distance to nearest: Well IV UJV C Foundation 'f Property Line DISPOSAL PONDS [l will be done in accordance with San Joaquin county ordinances, state laws, and I hereby certify that I have prepared this application and that the work rules and regulations of the San Joaquin Local Health District. hat in the pe Home owner or licensed agent's signature certifies the following: "I certifyperformance 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 all require inspections. Complete drawing on reverse side. s 1 �J,LfT1(/L_. Date: 6 / Signed X Title: FOR DEPARTMENT USE ONLY � � l\J�7�111 l�.— Area � plication Accepted by Date ` / _ Pi or Grout Inspection by Date b Final Inspection by Date dditional Comments: ❑ Stk 466-6781 ❑ Lodi -3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 }_ FEE AMOUNT DUE AMOUNT REMITTED CK S CASH RECEIVED BY -;OATE PERMIT' 0. z� INFO _ h r . EH 13-24(REV.i i n 5) rte, r