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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) 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 e or No. 1862 for welUpump and the Rules and Regulations of the San Joaquin made in compliance with San Joaquin County Ordinance No. 549 for sewag Local Health District. 777 _1.1 k7Ca — City Lot Size PM r Job Address { Phone Owner's Name ti Address Contractor Address ca / License No`.4 Phone TYPE OF WELL/PUMP: NEW WELL L WELL REPLACEMENT ❑ DESTRUCTION Ll PUMP INSTALLATION O SYSTEM REPAIR ❑ OTHER a t DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS a ❑ Ihdustrial ElOpen Bottom ❑ Manteca Dia. of Well Excavation A•� Dia. of Well Casing ' ❑ Domestic/Private ❑ Gravel Pack [a Tracy. ,. Type of Casing I Specifications ' �` f'1 f ublic i� Other Cl Delta � Depth of Grout Seal ' Type of Grout r , I Irrigation —_Approx. Depth ( I Eastern Surface Seal lnstalled.by Repair Work Done ❑ Type of Pump H.P. State Work Done 4 Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION; REPAIR/ADDITION (.I DESTRUCTION 1.l (No septic system permitted if public sewer is available within 200 feet.)_ Vp i Installation will serve: Residence Commercial_ Other Y r I Number of living units: Number of bedrooms S,3 , I rA Do Z3,6: ° Water table depth I Character of soil to a depth of 3 feet: SEPTIC TANK El Type/Mfg Capa itY,J No. Compartments PKG. TREATMENT PLT. ❑ r� �7- T Method of Disposal E Distance to nearest! Well -Foundation:1 .___ Property tine LEACHING LINE 'L)t' No. & Length of line a s � Total length/size FILTER BED 1-1 ��Distance to nearest: Well Foundation F ' -- Property Line °' SEEPAGE PITS lye Depth 5 '' Size �r.J` Number �r SUMPS ❑ Distance to nearest: Well Oar Foundation L(16--`Property Line ...— DISPOSAL PONDS ❑ At - 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. I I Home ownef^or licensed_agent's signature,certifies_th.a 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 a's to become 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 theworkfor which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applicant must cal( for'all re ired i pections. omplete drawing on reverse side. 1 Signed X Title:• r . ��i�.el� _ -- date: i j ( FOR DEPARTMENT USE ONLY k ! 0 7 Area Date t k Application Accepted by r Pit or Grout Inspection by 72 Date, Final inspection by Data f� Additional Comments: ' r ❑ Stk 466-6781. ❑ Lodi 369-3621 ❑ Manteca, 823-7104. ❑ Tracy 8351'6385 r Applicant - Return all copies'to:�Environmental Health Permit/Services 1601 E. Hazelton Ave., .P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. z INFO f ♦� EK'13"24(R£V.-VPHT)-'-#- ,. !l 3. .. + .G - �.. ...� .. f 0/;, EH 14-26 (J _