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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED > (Complete in Triplicate) ribed.This catim is Application is hereby made to the u anCoun w Ordinance No.District Local Health 549 for sewage or permit No 1852 forcwell/dpump install nd the Rules and Regulations of the Span Joaquin ' made in compliance with San Joaq County Local Health District: Ci Lot Size PM Job Address Phone Owners Name Address - r -{� 7 License No. Phone Contracto Address TYPE QF WELLIPUMP: NEW WELL ❑ WELL REPLACEMENT EI DESTRUCTION F1 SYSTEM REPAIR ❑ OTHER ❑ PUMP INSTALLATION ❑ DISPOSAL FLD. PROP. LINE DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES _ FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing E3 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Specifications R Type of Casing ❑ Domestic/Private 13 Gravel Pack ❑ Tracy Depth of Grout Seal Type of Grout 1. , ❑ Other ❑ Delta ❑ Public � �`: ---Approx. Depth ❑ Eastern '41 -Surface Seal Installed by ❑ Irrigation 'State Work Done Repair Work Done ❑ Type of Pump H.P. s Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler,Maierial (Below 50'1 TYPE OF SEPTIC'WORK: NEW INSTALLATION ❑ REPAIR/ADDITION C] DESTRUCTION ❑ a Nailabptiwkhst 200 feetitted if public sewer is L � , - gv i Installation vAl serve: Residence Commercial— Other F Number of living units:1— Number of bedrooms Water table depth d Character of soil to a depth of 3 feet: &- j p_� No. Compartments Capacl SEPTIC TANK Type/Mfg ty 4 Method of Disposal F PKG. TREATMENT PLT. ❑ _ _. n Distance to nearest: Well '' Foundation Property Line -- ��1t7 ( _ Total Iength/size LEACHING LINE No. & Length of lines Property Line ❑ Distance to nearest: Well Foundation I+ FILTER BED � l r Depth � ~Size . � Number y SEEPAGE PITS property Line _ SUMPS ❑ Distance to nearest: 1Nell' Foundation DISPOSAL PONDS ❑ - - - —- I hereby certify that I have prepared thrs•epplication 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. ed, l shall not Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issu 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." The applicant mus call for all requir d inspections. Complete drawing on reverse side. Title: Date: Signed FOR DEPARTM NT USE'ONLY Date Area F Application Accepted by Pit or Grout Inspection by Date 9 a� f- Final Inspection by Date Additional Comments: f ❑ Stk 4664MI ElLodi 369-3511 [1 Manteca 823-7104 ❑ Tracy 83�r6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 I --CK—i----1 FEE AMOUNT DUE AMOUNT REMITTED CKCASH RECEIVED SY DATE PERMIT N0. y INFO 4 + EH 13-24 IREV.1/B 5} lJ fes' EH 14-29 �,,: