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x APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 16'1 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED , rZle infie2ta) a urnocal Health s of ct�fo prtlrt to cons uct arld/osta e Ylred scribed. This application is A licatron is herebmde to he Jo q ns of the San Joaquin PP made in compliance with S oa in County Ordinance No. for s age or No. 1 or well/pump and the Rules and Regulations q Local Health DistrriAict. ,6 ' J , f� c� l�c � MV to, city Lot Size PM Job Address Owner's Name t �' Address Phone CL 1.l V W [L 3-7/s Phone Contractor's Name License No. TYPE OF WELL/PUMP: NEW WELL LlWELL REPLACEMENT ❑ DESTRUCTION f r PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ -• DISTANCE TO NEAREST: SEPTIC TANK �� —SEWER LINES _ DISPOSAL FLD. .POOP. LINE. f c r FOUNDATION F� AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS _. 1 1:1Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing rV ❑ Domestic/Private Ll Gravel Pack ' Tracy Type of-Casing Specifications w ❑ Public ❑ Other Ia❑ Delta Depth of Grout S681 Type of Grout D Irrigation ---Approx. Depth ❑ Eastern Surface Seai`-lnstalled by Repair Work Done ❑ Type of Pump H.P. ''� S ate Wor Done Well Destruction ❑ Well Diameter Sealing Material {top Depth Filler Material (Below.50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is I 4, available within 200 feet.) 1 ! Installation will serve: Residence_ Commercial_.— Other I '' Number of living units: Number of bedrooms ri 3 V Character of soil to a depth of 3 feet: Water table depth C I SEPTIC TANK ❑ Type/Mfg :I �"4 Capacity No. Compartments r PKG. TREATMENT PLT. ❑ Method of Disposal l Distance to nearestp Well foundation Property Line " Total len h/size h `' LEACHING LINE C3 No. & Length of lines - FILTER SED E1 Distance to nearest: Well Foundation Property-Line a ' SEEPAGE PITS ❑ Depth Size ,Number SUMPS 11Distance to nearest: Well Foundation Property Line 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 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 5 ��tempioy 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:" 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 talifornia. 1 ;+' ' The applicant cal r q- r s ons. Complete drawing on r rse side r —70)d Signed :µ Title: id`r1 '' l V� � Date: i 1 f` ( x FOR DEPARTMENT USE ONLY �`-� f� t Application Accepted by \ ' }CJ\ - i Date i 1— Area `' ��"'� tt-7� Final Ins ction by �L�C��— — Date Pit or Grout Inspection.by Date pe Additional Comments:t ❑ Stk• 466mMl "❑ Lodi 369-3621 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 n ii FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT"NO. INFO `` G + EK 13.24(REV.101631 _ EH 1425 I