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* �APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT kXT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate). Appall the work n describe . This cation is madeinti nt'compliance withdSan J aqu ne to the San County OrdinaJoaquin lnce Nto.549 for sewage orh District for a 'No. 1862 for t to cwell/dpump and the Rules and'R gulations of the San l Joaquin Local Health District. ) J '/P n '� /4 � ,p �� City� �1, Lot Size PM Job Address Owner's Name �e r WSJ t-1<6 Address S''4 114 � Phone16 3 Contractor,.. Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION El PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER El 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 1-1Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. f Well Casing El Domestic/Private El Gravel Pack El Tracy Type of Casing Specifications — F1 1 Public F1 Other Cl Delta Depth of Grout Seal Type of Grout I I Irrigation --Approx. Depth I I Eastern Surface Seal Installed by C7� Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I l REPAIR/ADDITION I 1 DESTRUCTION (Noseptic sthin system permitted if public sewer is \� Installation will serve: Residence_ Commercial_ Other 'availab Number of living units: Number of bedrooms Character of soil 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 SEEPAGE PITS I I Depth Size _ Number SUMPS Cl 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 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 applicant must call for all required inspections. Complete drawing on reverse side. ®� Signed X��(e(1�� TitJe: ��K 'f? R Date: FOR DEPARTMENT USE ONLY Application Accepted by � Date `3�� Area Pit or Grout Inspection by Date Final Inspection by �,� '+/ Date f Additional Comments: , �✓ - — 9 '�� ❑ 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 REMITTED K RECEIVED BY DATE PERMIT'NO. INFO � nvn1� +.EH 13-24(REV.I/H5) EH 14-28