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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 4'YEAR FROM DATE ISSUED (Complete in Triplicate) I r 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 made irtcompliance with San Joaquin.Cou 0 dEnance'No 54Wfar kawage or No. 1862 for welUpump and the Rules and Regulations of the San Joaquin Local Health District ' r 1 � 1 C A' I_ ;j,'. Job Address °•" (� l City, Lot Size PM p , Owner's Name Address iq Phone p Contractor Address rise No. �Ir Phone_ TYPE OF WELLIPUMP: NEW WELL WELL_REPLACEMENT ❑ _ DESTRUCTION ❑ PUMP INSTALLATION ❑ YSTE PAIR-❑� N OTHER El DISTANCE TO NEAREST: SEPTIC TANK �s.��— SEWER LINES POSAL FLD. `_, -PROP. LINE FOUNDATION .AGRICULTURE WELL. OTHER WELLPITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS r TJ Y // ❑ Industrial` ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Domestic/Private- Q Gravel Pack ❑ Tracy Type of Casing 10 Specifications . N F1 Public J f i Other ❑ Delta Depth of Grout Seal hn n Type of Grout :y I 1 Irrigation 19 1) Approx. Depth i I Eastern 4 Y Surface Seal Installed by— Repair y—Repair Work Done .❑ Type-of Pump H.P. State Work Donee $ Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filier Material (Below 601 TYPE OF SEPTIC WORK: NEW INSTALLATION Cl REPAIR/ADDITION LI DESTRUCTION I I iNo septic system permitted if public sewer is available within 200 feet.] Installation will serve: ResidenceOther Number of living units: Number'of bedrooms Character of soil to a depth of 3 feet: ' Water table depih O' SEPTIC TANK. ❑ Type/Mf g"'°""'-` Capacity L__'- No. Compartments PKG. TREATMENT PLT. ❑ , _ _ _ v 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 ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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, an ` 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: "1 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 Ca'fornia." The appli ant ust call for all requ' d inspection . Com to ra ng on averse side.. II Signed X Title: Date: A OR DEPARTMENT USE ffNLY �7 7 Application Accepted by Da#e ' �f c- Pit or Grout Inspection byt _ Date Final Inspection by ' Additional Comments ❑ Stk 466-6781 ❑ Lodi 369-3@21 ❑ Manteca 823-7104 ❑ Tracy 835-6385 1 f Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk.4,vl �/elI ' P MINT � FEE AMOUNT DUE AMOUNT REMITTEDCK H RECEIVED BY DATE P INFO y'Iyr J/��/ + EH 13,24(REV.I/N 51 "�' / "' EH 14-26