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`��'�,"� APPLICATION FOR PERMIT, r �• .. , SAN JOAaUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA "I Telephone (209) 466,6751 2 ' 1 � "'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 inance No. 549 for sewage or/No. fitforowellump�nthe Rules and Regulations e San Joaquin Local Health District. I Z��ll ( +L f C/lf�/ Ei ,I� �� [ City r�f<(��l=C PM _ ; q-M kJ � i f Lot Si,_ Job Address E?V_ Q , L2,va/d rr �{ e i�u � f t �1Z<`Y � Ji e --�e_,,Phone �� 3 Owner's Name 6>��{� r r �� Address -� f Contractor 'f.l r �_-t fh Address j � a ; License No, �� Phone— &�I-�� 1 -- f TYPE OF WELLIPUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION E3 PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST:.SEPTIC TANK 1"QkI " SEWER LINES DISPOSAL FLD.1%6 i _ PROP. LINE kt& X FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS 13Z,_he? Ir7� t INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS -�`❑ industrialOpen Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing J 441)omestic/Private ❑ Gravel Pack ❑ Tracy Type of CGrout � t'tr Specifications Cl Other F1 Delta Depth of Grout Sal Typo of GtoFI Public L I 1 Irrigation �� )_Approx. Depth 1 I Eastern Surface Seal Installed byI/" 1- Repair Work Done ❑ Type of Pump f H.P. �State Work-Done +� Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 50'1 =— TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION l 1 DESTRUCTION t 1 (No septic system permitted if public sewe"is .available within 200 feetA installation will serve: Resldence'� Commercial""- Other _ _ _ �r�of `✓r Numbe of liming units: Number bedrooms yti Character of soil to a depth of 3 feet: n Water table depth"? 1No. Com artments SEPTIC TANK ClTypelMfg ;- Capacity P PKG. TREATMENT PLT. ❑ r c 'Method-of-Disposal . Distance`to nearest: Well Foundation Property Line Y LEACHING LINE; ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line` i Number SEEPAGE PITS 1 1 Depth Size �'""#'' -Su ,lP5 Ll Distance to,nearest Well Foundation Property Line DISPOSAL PONDS ❑ hereby-certify that) have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and Erules and regulations''of the San Joaquin Local Health Di§trict. 1 _ owing: "I certify that in the performance of the work for which this permit is issued, I shall not Home owner or licensed agent's signature certifies the fell employ any person in such manner as to-become subject to workman's compensation laws of California." Contractor's hiring or sub contracting signature h certifies the following: "l certify that in the performance of the work for which this permit is issued,l shall employ persons subject to workman's compensa- tion laws of California." The applicant must call for all requir d inspections. Complete drawing on reverse side. _a Signed t i �� Title: - Date: t FOR DEP ONLY e;S Application Accepted by Date � r Area Pito Gr t Inspection by� Dat <� Final inspection byDate i wsAdditional-Comments:'1 — ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 623-7104 ❑ Tracy 835-6385 r� Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201. 4 FEE MOUNT DUE AMOUNT REMITTED CASH RECEIVED l3Y DATE PERMIT N0. INFO 313 ♦ EH 13-24(REV.1/95� `p -Q�i Cllr, �( / �GY��" - EH 14-28 ' V ti 73