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APPLICATION FOR PERMIT A' SAN JOAQUIN LOCAL HEALTH DISTRICT �,Qo� or P.pk�' 1601 E. HAZEIT ON AVE., STOCKTON, CAS Telephone (209) 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED (Complete in Triplicate) /or install the rk . This cation is Application is hereby made othe Joaquin County ordinance No.549 for sewage or ealth District for a No�1862 forcweli/pump and the Rues and hereinR Regulations of the San g Joaquin made in compliance with San Local Health District t Size ` .�� _.�_�" PM .fob Address /l �� City,�/ ✓D/✓i U /��/1WaoG/ � � Phone Owner's Name Address Contractor Address License No._ Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ SEWER LINES __�-- DISPOSAL FLD. PROP. LINE DISTANCE TO NEAREST: SEPTIC TANK PITS/SUMPS FOUNDATION AGRICULTURE WELL OTHER WELL INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing !P Type of Casing 7F�' Specifications ❑ Domestic/Private, ❑ Gravel Pack ❑ Tracy Type of Grout — f'] Public Cl Other Cl Delta Depth of Grout Seal I I Irrigation —.Approx. Depth I I Eastern Surface Seal Installed by H P Sta Wor Done h Repair Work Done ❑ Type of Pump 4 ?•} Wel! Destruction �9 Well Qiameter _.S2—_— Sealing Material (top 50'I \ Depth_. � .Filler Material {Below 501) TYPE OF SEPTIC WORK: NEW INSTALLATION 1:1 REPAIR/ADDITION l 1 DESTRUCTION I i availablle'wthin 200 feeperstem t't�ed if public sewer is t Installation will serve: Residence_ Commercial — Other + N) Number of living units: Number of bedrooms a e •+— --Water-table depth Character of soil to a depth of 3 feet: No. Compartments SEPTIC TANK ❑ Type/Mfg Capacity Method of Disposal 1 PKG. TREATMENT PLT. ❑ f Distance to nearest: Well Foundation Property Line Total length/size LEACHING LINE ❑ No. & Length of lines FILTER BED ElDistance to nearest: Well Foundation Property Line SEEPAGE PITS i 1 Depth e Size Number SUMPS 1 I 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 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 the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." I The applicant must call for all required inspections. Complete drawing on reverse side. 1�� w Date: F Signed X-�� -� Title: R DEPARTMENT USE ONLY 4 r Date L� A Area s Application Accepted by ' Date ��d + Pit or Grout Inspection by Final Inspection by Date; Additional Comments: ❑ Stk 456-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 - ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.D. Box 2009, Stk., CA 95201 i FEE CK RECEIVED BY DATE PERM4T'NO. INFO AMOUNT DUE AMOUNT REMITTED CASH +.Eli 13.24 IREV.r i n sl � �l�� -3, Ca��- vx EH 14-29