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—/Z U ak APPLICATION FOR PERMIT a Q. SAN JOAQUIN LOCAL HEALTH DISTRICT W 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED (Complete in Triplicate) t and/or install the work herein described. This cation is madle inti ompliance with made SanoJoaquin the Couty Ordinance n Joaquin lNo.549 for sewage o Health District for a permit 1862 for cwell/pump and he Rules and Regulations of he San l Joaquin Local Health District. ' � UXf1a City Lot Size PM I Job Address /�� l • 1 x Owner's Name ddress / Phone `/ f I Contractor Address License No. Phone TYPE OF WELL/P MP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ i PUMP INSTALLATION ❑ SYSTEM 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 w EJ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. f Well Casing 0 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public Fl Other Cl Delta Depth of Grout Seal Type of GrouE - t I i Irrigation -- PP PA rox. Depth l I Eastern Surface Seal Installed by - Repair Work Done ❑ Type of Pump H.P, State Work Done _ jWell Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION LI DESTRUCTION l (N.septtravailablewt Sne200 feet. tlt�ed if public sewer is Installation will serve: Residence, Commercial_ Other Number of living units: Number of bedrooms Character of sail to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments" PKG. TREATMENT PLT. ❑ 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 w SEEPAGE PITS I I Depth Size Number SUMPS Ll 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, 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 traced, I shall not -contracting signature employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub 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- I tion laws of California." The applicant must call for.all requ'red inspections. omplete drawing on reverse side. Signed X Title: ©lam Date: FOR DEPARTMENT USE ONLY Application Accepted by Date ` 3 Area v Pit or Grout inspection b Date ... Final Inspection by ` - Date Additional Commen ❑ Stk 466-6781 ❑ Lodi 69-3921 ❑ Manteca 823-7104 ❑ Tracy 835-6385 �r Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box tk., CA 95201 .� tpl/OA2 %n4 b e, -/,7 ss FEE AMOUNT DUE AMOUNT REMITTED ASH RECEIVED BY DATE PERMIT NO. - t + EH 13-24(REV.I/x 5) INFO � ti - a� L I EH 14-26 .•// .