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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) all the work cation is made in comp heteby lance with Saade nJoaqu nthe nCounty ordinance uin Local No. 549 for sewage or ealth District for a permit No. 1862 forcwell/dpump atnd the Rules and herein R Regulations of the San Joaquin Local Health District. ! Cit Lat Size PM Job Address Address Phone Owner's Name , Contractor s Address License Noce �3� Phone 16e,! TYPE OF WELL/PUMP: WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ , PUMP INSTALLATION ;w SYSTEM REPAIROTHER ❑ A-6 / DISTANCE TO NEAREST: SEPTIC TANK ISO k- SEWER LINES DISPOSAL FLD.A_ A& PROP. LINE FOUNDATION . A - AGRICULTURE WELL OTHER WELL A LQh 1Ph 1P_ PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 0 Industrial Open Bottom ❑ Manteca Dia- of Well Excavation Dia. of Well Casing R'l r ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications (S� f"1 Public I--I Other F1 Delta Depth of Grout Seal Type of Grout _. GIN Irrigation -3m.Approx. Depth i I Eastern Surface Seal Installed by - repair Work Done g Type of Pump H,P 1 K . State Work Done L_)9 Q Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I] REPAIR/ADDITION I I DESTRUCTION { I (No septic system permitted it public sewer is t1 available within 200 feet.) installation will serve: Residence— Commercial_ Other Number of living units: Number of bedrooms— S Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments !\� PKG. TREATMENT PLT, ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that t 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 person in such manner as to became subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following: "I 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." The applicant m t call for all require inspectionS--Complete drawing on reverse side Signed A L�_� Title: �' Date: OR DEPARTMENT USE ONLY 3 Q Application Accepted by Date Area Pit or Grout Inspection by Date Final Inspection by Date _Additional Comments: ❑ Stk 466-6781 ❑ 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 ffFEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT-NO. +.EH 13-24 i REV,1/95) EH 14-26