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{ s APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA N-N V q Telephone (209) 466-6781 001 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate)h District for a j . This Applcation is ication is hereby made to the uan Gou Quin Local Healt Ordinance No. 549 for sewage or IN No. 1962 forcwelllpump and the Rules and t and/or install the work herein Regulationa of he Sanl Joaquin made in compliance with San Jolaq tY Local Health District. I ! r f l I t0c_�_4m Lot Size PM Job Address C %exv-Aw- City f I 1 Phone lIp ~[frGac:Tv'Address s�� 1''� , C+'1 4Y w c. Owner's Name License No. 512.ZCA_$ Phone_ �a Contractor Address 2$LS r LNy �r II TYPE OF WELL/PUMP: I� NEW WELL WELL REPLACEMENT El DE ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR © OTHER 9 Sot) �aor+k%s �� tI TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE DISTANCE ' FOUNDATION AGRICULTURE WELL OTHER WELL CONSTRUCTION SPECIFICATIONS PITS/SUMPS ' INTENDED USE TYPE OF WELL PROBLEM AREA l o ❑ MDia- of Well Excavation a Dia. of Well Casing ❑ Industrial Elanteca pen Bottom Type of Casing QV Specifications IJ Domestic/Private Gravel Pack © Tracy yp t Type of Grout ["1 Public Cl Other ❑ Delta Depth of Grout Seal i .I. _ I I Irrigation �._Approx. Depth l l Eastern Surface Seal Installed by �otti�r4 i State Work Done H P _ `Repair Work Done ❑ Typh of Pump u . Well Destruction ❑ Well Diameter QVC- Sealing Material Itop 5D'1 — �n Depth Df Filler Material (Below 50`1 V l TYPE OF SEPTIC WORK: NEW INSTALLATION I.l REPAMIADDITION l I DESTRUCTION I i (No septic system permitted if public sewer is i il� available within 200 feet.) Installation will serve: Residence— Commercial— Other Number of living units: jjL Number of bedrooms Water table depth Character of sail to a depth]of 3 feet: SEPTIC TANK ❑ Type/Mfg Capacity. No. Compartments PKG. TREATMENT PLT- ❑ Method of Disposal �. I Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size I FILTER BED ❑ I Distance to nearest: Well Foundation Property Line 1 SEEPAGE PITS I I Depth Size Number SUMPS 11 ' Distance 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 employ any parson in such manner as to become subject to workman's compensation laws of California." Contractors hiring or sub-contracting signature certifies the personfollowing:iI certify 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 California." ,III The applican ust tali for all required inspections. Complete drawing on reverse side. Signed X Title: _,�� Date: FO PAR USE ONLY Application Accepted by Date Ih ,_' Pit or Grout Inspection h bat Final Inspection by Date's " Additional Comments: I� ❑ Stk 466-6781 ❑ L`odi 369-3621 ❑ Manteca 823-7164 ❑ Tracy 835-6385 Applicant - Return all copiesto: Environmental health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95261 ffEE! K RECEIVED BY DATE PERMIT'NO. AMOUNT REMITTED H 4EH 13-24 fAEV.EH t4-2s �QO + SII 1