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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA � Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Appt and/or install the work cation is made n conmpliance ws heieby ithde tSanoJoaquin CountyOrdinathe SaJoaquin lncfe No. 549 for sewage orealth District for a 't to No. 1862 forcwell pump and the Rules and hereinR gulations of the San'Joaquin Local Health District. h / Job Address ,��0 9 A7-i 1A66AJ City 1 Lot Size PM ��^/� GGG,CaSdy Address SO Phone Owner's Name u Contractor,0 f'' Address /l, 4►IL 4VA License No. Phone `�-946 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEM NT ❑ DESTRUCTION ❑ 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 Ll Industrial L1 Open Bottom El Manteca Dia. of Well Excavation Dia. of Well Casing 11 Domestic/Private ElGravel Pack LlTracy Type of Casing Specifications FI Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout — I I Irrigation _Approx. Depth l I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') -- TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION>4 DESTRUCTION ( I (No septic systemithin rented if public sewer isavailable 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 ❑ Type/Mfg Capacity No.-Cpmpartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE JPV No. & Length of lines ' Total length/size D FILTER BED ❑ Distance to nearest: Well Foundation `D Property Line SEEPAGE PITS 141k, Depth As Size �3 X � Number SUMPS ❑ Distance to nearest: Well dW/ Foundation lat 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. Q �t 9 Signed X &m Title: 621Date: s ,,,,,, FOR ��DEPARTMENT USE ONLY / p Application Accepted by Date( �/ Area , j CJ t or Grout Inspection by ` Date Final Inspection by Date UUUAdditional Comments: ❑ 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 CCK#, RECEIVED BY DATE PERMIT NO. INFO CASH +.EH 13-24(REV.I/H 5) EH 14-26 '4