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i APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT j 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Tws t and/or install the work Application made com ante with Sano the Joaqu n Coucation is nty Ordinuin ance No.District Health 49 for sewagn Jo e or'No. 1862 fort to cwall pump and the Rul s and herein Rgulations of the Sang Joaquin m P Local Health District. City Lot Size ' r PM Job Address E { _ D ' Phone t Owner's Name ' �� "��` dpdressss Phone 17 Contractor's Name License No. TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT❑ DESTRUCTION ❑ PUMP INSTALLATION_ _. SYSTE_MM REPAIR ❑ t OTHER ❑ _ r _ SEWER LINES DISPOSAL FLD. ' PROP. LINE ' T DISTANCE TO NEAREST: SEPTIC TANK PITS/SUMPS FOUNDATION AGRkCULTU RE WELL OTHER WELL f INTENDED USE TYPE OF WELL PROBLEM AREA. CONSTRUCTION SPECIFICATIONS H of Well Casing { ❑ Industrial 'Open Bottom ❑ Manteca Dia. of Well Excavatttiiion ��- 'T a of Casing T Specifications .. XDomestic/Private ❑ Gravel Pack 1-1 Tracy YP _ g Type of Grout r ❑ Public ❑ Other ❑ Delta Depth of Grout Seal L' � [I Irrigation �pprox. Depth El Eastern Surface Seal Installed by Type of Pump ' —if H.P. State Work Done r Repair Work Dane TYP • I Well Destruction Well Diameter ,, Sealing Material {top 501 m Depth �0r`� ' Filler Material (Below 50'1 { `TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ aNailablewithin a200 feet.) if public sewer is ' n 'Installation will serve: Residence_ Commercial— Other s Number of living units: Number of bedrooms Water table depth E Character of soil to a depth of 3 feet: No. Compartments Capacity 11 "SEPTIC TANK ❑ Type/Mfg Method of Disposal k PKG. TREATMENT PLT. ❑ f Distance to nearest: Well Foundation Property Line l Total length/size LEACHING LINE ❑ No. & Length of lines r� FILTER BED F-1Distanceto nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size .Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ ll be done in accordance with San Joaquin county ordinances, state laws, and 1 hereby certify that I have prepared this application and that the work wi rules and regulations of the San Joaquin Local Health District. I 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 CaVornia." + The applicant must call for all required inspections.'Complete drawing on fe rse side. .. •�J Title:. 6iiDate: Signed: ��`� f FOR DEPARTMENT USE ONLY F. Date Area / Application Accepted by � �L/ Pit or Grout Inspection by ate/ FinalZ Inspection by Date / Additional Comments: ll ❑ Stk 466-6781 Lodi 369 3621 ❑ Manteca 823-7104 ❑ Tracy 835 6385 Applicant Return all coot to: EnvironmentalkHeaith Permit/Services 1601 E. Hazelton Ave., P.O. Sox 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE �PERMIT`NO. 730 jA,-f + EH 1324(REV.14163) _ - EH 1428 ....._ _...