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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HA7_EL T 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 made in compliance with San Joaquin County Ordinance No. 549 lot sewago or No. 11162 for well/pugtp and Or 7ules apd Regulations of the San Joaquin Local Health District. r I Job Address ___ Ahjyr✓I% ,Gaol �°� �r t�,� City SL0__— Lot Size PM ��(f re/d E <�_.. YVl I r/ �"�Address __.__ ---- -- Phone .01_ 9,1 Z _1 Owner's Name/ _/__ _ _/_---.------�-------._..---------- Contractor �(yh_l._---vt"_/ll! .._`.._.Address .�0. %` �-__J°(_} J?nf. ---LicenseNo.-_ �7?a1_4j Phone2„Al_?1_3-_�// TYPE OF WELL/PUMP: NEW WELL $,d' WELL REPLACEMENT I DESTRUCTION LI AMOUNT REMITTED ____-.-__ PUMP INSTALLATION 1.1 SYSTEM REPAIR (I OTHER _. DISTANCE TO NEAREST: SEPTIC TANK .__.._____.____ SEWER LINES __.—__ DISPOSAL FED. PROP. LINE FOUNDATION ___._._-.-___ AGRICULTURE WELL —OTHER WELL_TQ,,�_— PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATION$ 7� I 1 Industrial I I Open Bottom I I Manteca Dia of Well Fxcavabon _—_46�—_�_/—�_� Dia. of Well Casing jA D rnestic/Private h Iti f(f Gravel Pack I I Tracy Type of Specifications nth* rr , 1'I uhlic 1 1 Other >�d 11 Delta Depth of Grout Seal—�1�_—_-- Type of Grout a kr 1 I I Irrigation A_'Approx. Depth 1 I Eastorn Sudaco Seal Installed by. -- Repair Work Done I 1 Type of Pump —________ __. H.P. State Work Done Well Destruction I I Well Diameter _ _._ __. _ Sealing Material (lot) 50') -- Depth --______-_ -___ ___... Filler Material (Below 50'1 _._____----.-.-----------------------._------ IYPE OF SEP IIC WORK: NEW INSIAt LAIION I I Ili PAIR/ADDIIION i I DLSTRUCTION I I INo septic system permitted it public sewer is available within 200 feet.) Installation will serve: Residence _ __ Commercial - Other _ . _ __ . - -, _._ Number of living units: ___ _ Number of hodrooms Character of soil to a depth of 3 feet: SEPTIC TANK I I hype/Mfg PKG. TREATMENT PLT. I I Capacity Distance to nearest: Well __ Foundation LEACHING UNE I I No. & Length of lines FILTER BED I I Distance to nearest: Well Foundation SEEPAGE PITS I I Depth_ -- SUMPS I I Distance to nearest: Well _ Foundation DISPOSAL PONDS I 1 —Water table depth - _- No. Compartments Method of Disposal Property Line , Total length /size.--- _-__ Property Line Number - __ Property Line 1 hereby certify that 1 have prepared this application and that the work will hu donu 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 signattue certifies the following: "I cnrtify that in the performance of the work for which this permit is issued, I shall not employ any person in such mannor 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 {wrfomtance of the work for which this porinit is issued, I shall employ persons subject to workman's compensa tion laws of California." The applicant m t ca11 for 11 refit Trod inspections. Comploto drawing on reverse side. Signed X -1L _ i r+ i•� r --- - -- Title: — - 1 "� iSDate: 4/ FOR DEPARTMENT USE ONLY -�� Application Accepted by _�,;j �f••=- .1 �:T,a:,,�!�.x�t.'-_-.c' '� Date Area cr �• s_ Pit or Grout Inspection by —_--.__ Data Final Inspection by Date Additional Comments: _0_�1.t-:_—� s` y ��i ji l - : /' >,, 11.+ "i---7 - -=. , .ler ., Cl Slit 466-6781 LJ Lodi 369-3621 LJ Mantecte 823-7104 Cl Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazolton Ave., P.O.`Soii 2009, Sik., CA 95201 • EH 13-24 IREV. t,95 EH 1416 FEEMOUNT INFO OUE _ AMOUNT REMITTED ____-.-__ CK CASH _ RECEIVED BY DATE _ PERMIT'NO.