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APPLICATION FOR PERMIT - - SAN JOAQUIN LOCAL HEALTH DISTRICT ° 1601 E. HAZELTON AVE., STOCKTON, CA t ( I Telephone (209) 466-6781 _ 12 i 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 age or No;1ti82 for well/pump and the Rules and Regulations of the San Joaquin made in compliance with San Joaquin County Ordinance No.549 for sew Local Health District. Uf L Cm �'\ �� Lot Size C��— PM Job Address ,'. , �_ r f Phone Owner's 1Va 1e Address L�F LT�F�1--)-- Address �5O �N ' �t icense No.�5 one J T 2 t"6 t Contractor- -TTFPE'OF-WELL-/PIJMp'- -`-"'NEW-WECL❑"." -WELL-REPDXCEMENT-0 DESTRUCTION PUMP INSTALLATION ❑ SYSTEM REPAIR -1 OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD._ PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL _ PITS/SUMPS 'NTE-LADED-USEr---TYPE-OF-WELL-..--PROBLEM.AREA—CONSTRUCT-ION-SPEGFICATIONS-�--- ---- --��— ; ❑ Indus iiai l ❑ Open Bottom ❑ Manteca?' Dia. of-Well Excavation Dia. of Well Casing i { - -' r Specifications f ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy f Type of'Casing {_ .,. . Type of Grout ❑ Public, ❑ Other i O Delta Depth of Grout Seal Yp ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by f L N State Work Dane Repair Work Done ❑ Type of Pump H.P. Well Des6ction ❑ Well Diameter' — '- Sealing Material-top 50'1 -- - t Depth _ Filler Material (Below 501 I W TYPE OF�SEPTIC WORK: NEW INSTALLATION ❑ REPAIR!ADDITION 9i DESTRUCTION ElfNo septic system permitted if public se r is ! available within 200 feet.) Installation will serve: Residence t-commercial __ ther-- i Number of Irving units: L_- Number of edrooms - -_ I (� Character of soil to a depth of 3 feet: I , 'ice - -Water table depth SEPTIC TANK �-Type/Mfg I ! Capacityp�Z No. Compartments PKG. TREATMENT PLT. C -t Method of is sal ' 1 Distance to nearest: well�� Foundation _Property Line - i ` t Total length/size LEACHING LINE IsvNo. & Length'of lines„` � �_ 9ih i FILTER BED ❑ Distance to nearest: Well # _-_— Foundation Property Line 1 _ - I SEEPAGE PITS L,-I epth ' _ _t' '7 Size Num SUMPS ElDistance to nearest:,41 iWell _ fi Foundation -- Property Line i I f DISPOSAL PONDS. . 0, I hereby certify that I have.prepared'this appllcation.and_that the Jirbrk,will_be,done in accordance with San Joaquin county ordinances, state laws, and rules arid.regulations of the San Joaquin_;bocal Health District.` ✓ Home owner or licensed agent's signature.'oertifies the-following: "I certify that in the performance of the work for which this permit is issued,I shall not oy any person I such manner as to become subject to workman's compensation laws of California."Contractors hiring or sub contracting signature cart the following."I certify that in the performance of the;woik for which thisrpermit is issued,I shall employ persons subject to workman's'con-lpensa- tion laws California. Iy s< The applicant st call fo II re ired i I ctl plate drawing o reverse'side. � �./t _ Date: r Signe Tide: r tt y I FOR DEPARTMENT USE ONLY I r _ �. o Application Accepted by — Date Area •,' Pit or Grout inspection by ate l F i►al Inspection by .— Data _ Addltionil Comments: } Stk 466-Ml ❑ Lodi 369-3621 17J Manteca 823-7104 ElTrao k)r 863 Applicant- Return all copies to: Environmental Health Perm(t%Services 1601 E. Hazelton Ave.,,P.O. Box 2009,,Stk-, CA 95201 FEE AMOUNT DUE AMOUNT REMI�fED� RECEIVED BY DATE PERMIT NO. INFO ' /� EH 13-24(REV.t Ft5; - �--�S d��S EH 14-25