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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 E PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) 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 or No. 1862 for welllpump and the Rules and Regulations of the San Joaquin made in compliance with San Joaquin County Ordinance No.549 for sewage f Local Health District. [� L�f City Lot Size 160 7 f PM Job Address ��// Address &2& Phone r Owrier's Name �i C Contractor's !Name � License No. ��: Phone It—`S ` 3 TYPE OF WELL/PUMP: NEW WELL LJWELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ -� DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE ` FOUNDATION AGRICULTURE WELL OTHER WELL--PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS pia of Well Casing ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Specifications D Domestic/Private ❑ Gravel Pack ❑ Tracy Type of.Casing , p ❑ Public ❑ Other El Delta - Depth-of--Grod.-Seal. Type of Grout I ❑ Irrigation ---Approx. Depth ❑ Eastern "Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. '+ State Work Done C[Z F Well Destruction ❑ Well Diameter Sealing Material {top 501 v , Depth Filler Material {Below 50') I TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ "DESTRUCTION ❑ INo septic system permitted if public sewer is r available within 200 feet.) c#— t Installation will serve: Residence— Commercial Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK Er-Type/Mfg Capacity— . .5 2 — No. Compartments PKG. TREATMENT PLT. ❑ f Method of Disposal { Distance to nearest: Well Foundation Property Line LEACHING LINE E7'No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: WeA, Foundation Property Line �- SEEPAGE PITS ❑ Depth Size d�X! F x��` Number �� SUMPS E3I istance to nearest: Well Foundation Property'Line� +r—� DISPOSAL PONDS Cl 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 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 California." The applica st c Dfor all q ire inspections. Complete drawing`on reverse side. rn. Date: Signed Title:._ I FOR EDEPA"RA AreaApplication Accepted by Pit or Grout Inspection byTDate'- Date Of Additional Comments:❑ Stk 466-6'781 ❑ Lodi 369-3621 ❑ Manteca 823-710 - Applicant- Return all copies to: Environmental Health Permit/Services'1601�E. Hazelton Ave., P.O:-Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CA HE!!HIE7; PERMIT"N0. INFO ` + EH 13-241REV.10/831 �°� -� -� EH 1428