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a APPLICATION,FOR PERMIT SAN JOAQUIN 10CAL;HEALTH DISTRICT i 1601 E.MAZEL TON AVE., STOCKTON, CA Tefephone (209) 46( -6781, ''?r■ t }rr�4,_ iF)rl in of " #5` i1 'X.�'1 io PERMIT EXPIRES 7-YEAH FROM,D.ATE_ISSVED_,,i,_ ill,to � I d.Cl�''r.' - •nr ..'-'yd„a c „1" ., 1 {COlfl lets in, Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein descri6ed. This application is made in coinpliance:With;San Joaquin.County.Or-dinance''No.�549.for.se wage or`No.;1862 for:well/pump,and_the-Rules and_Regulatiohs of the San Joaquin Local Health District. s x c !C- t:3 l e a r� ill; .i-!iYtz'v�'3�.�:1 �Pt ?;�.�,CS. C` '1 3..YtC1 a"t. �G ';��:: C..��U+�% f..��L :_�" A}e^ �i�� tf it , '��`i� .oi"'i .J i"':'} 5/`W 1��y ('3Si�° yt1 'f '� ') i"7 fy+"�iJt 7iLs..Y � Job Address [U�eQ � �� a City -�✓ Lot Size 9• -PM Owner's Name zi. Address Phone Contractor's Name f L_icense'N_o. -��- � Phoned ti TYPE OFWELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑.,—'� _ DESTRUCTION d PUMP'INSTALLATION ❑ -3` '" - SYSTEM,REPAIR ❑ OTHER El- DISTANCE TO NEAREST:_SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE. F FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED,USE TYPE OF WELL •PROBLEM AREA CONSTRUCTION SPECIFICATIONS L - ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ; ❑ Public L)'Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation _ --L-Approx.' Depth- ❑ Eastern. Surface Seal Installed.by Repair Work Done ❑ Type of Pump / H.P. State Work'Done ` Well Destruction ❑ Well Diameter Sealing Material (top-50']; Depth.. ? Filler Material (Below_ ;50'] ` TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION El (No septic system permitted if public sewer is s .. - a - �:l .; - . _. available within 200 feet.i, Installation will serve: Residence_ Commercial Other i Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: A Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG`. TREATMENT'PLT?❑ �' Method of Disposal i h 'Distance to nearest: Well; Foundation Property Line01 > LEACHING LINE ❑I No. & Length of lines Total length/size 'FILTER BED ❑ Distance to nearest: ;Well 'Foundation Q, 'Property Line , -SEEPAGE PITS p d :Depth J 5— Size Number SUMPS " ` ❑ ;Distance to nearest: Well Foundation -Property Line d DISPOSAL PONDS._... :.El 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, an rules and regulations-of the San Joaquin Local-Health-District. - v. r ' - Home owner or licensed agent's signature certifies the following: "I certify that in the performance of,the ork for which this permit is issued,.I shall no!t +employ any person in such manner as-to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signaturis , certifies the following:"Iicertify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion g -' ,Saws of Calif a .. „ } •� " � - � . ry t. The applicant st II f I e rnspe' ns. plete drawin on revs side Signed Title: i Date: DEPART USE ONLY is Application Accepted by Date Ar �} Pit or Grout Inspection by r M Datel Final Inspection by Date j- ._ l Additional Comments: foe ❑ Stk 466-M1 ❑Lodi "369-3621 -❑--Manteca- 823-7104- -7 -❑Tracy 835-6385 Applicant- Return all copies to: Envlrorimental'Health Permit/Services 1601 E. Hazelton Ave., P.O: Box 2009, Stk.; CA 95201 INFO AMOUNT DUE , AMOUNT REMITTED CASH i RECEIVED BY t DATE. PERMIT'NO. . .{_ �- r ._ - _. f ,+EH 13-241REV 40!834 I t -j ' -,,. EH 14-28 i - '