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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 r PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) t an /or install the work n describe . This Application is hereby made cation is nnJoa Joaquin coungty O d nance No.549 for sewage or Health District for a permit 1862 for cweli/pump and the Rules and rft gulations of the San j Joaquin made in compliance with Sa q Local Health District. Cit /i/ Lot Size PM Job Address Phone ddress Owner's Namee - Contractor. - Address.' ' License No._Phone TYPE OF WELL/PUMP: NEW WELL El WELL REPLACEMENT DESTRUCTION ❑ ❑ 51 'PUMP INSTALLATION 0 'STEM REPAIR'❑"" " ��"�' —OTHER"❑" 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 pia. of Well Casing L1 Industrial ❑ Open Bottom ❑ Manteca - Dia'of Well Excavation Specifications LJ Domestic/Private ❑ Gravel Pack L1 Tracy r Type of Casing lCl Depth of Grout Seal Type of Grout I'1 Public P Other Delta tailed b Approx. Depth i I Eastern Surface Seal Ins y I I irrigation State Work Done — Repair Work pone ❑ Type of Pump H,P. N " Well Destruction — ❑ Well Diameter � Sealing Material (top 501 ` Depth Filler Material (Below 50') TYPE DF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION 1 1 DESTRUCTION I I atvo septtrlablew thir1em rented if public sewer is I eetJ installation will serve: Residence Commercial ; Other_ - `' r Number of living units: �— Number of bedrooms - 5 +4- _ Water table depth t Character of soil to a depth of 3 feet: ❑ Type/Mfg Capacity No. Compartments SEPTIC TANK Method of Disposal r PKG. TREATMENT PLT. ❑ Property.Line Distance to nearest: "� Well !Foundation k LEACHING LINE ❑ No. & Length of lines' Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line r I Depth Size Number SEEPAGE PITS Property Line SUMPS Ll Distance to nearest: Well Foundation DISPOSAL PONDS ❑ I 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 F rules and regulations of the San Joaquin Local Health Dli trict. 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 I 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." f The applican must call for all required inspections. Complete drawing on reverse side. ' � ate: la: e � Signed X m FOR DEPARTMENT USE ONLY � Date v r `� Area Date Pit or Grout Inspection j Application Accepted by p i O pate r Final Inspection by Additional Comments: El 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 FEE AMOUNT DUE AMOUNT REINITTEO O RECEIVE) By DATE PERMIT NO. INFO r +.EH 13-24 IREV,ti i e 5l C'� t p -�•1 EH 14-26 •••r