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APPLICATION FOR PERMIT u SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) cation is Application is hereby made to the u nnCounty OrdinaJoaquin Localncie No.549 for sewage or it 1862 forcwell/dpump and the Runes a%n Regulations of the San) made in compliance with San JoaqJoaquin Local Health District. Job Address City Lot Size PM � Owner's Name �f I� ` � � "�v Address _.$1— S EL 4 - Phone Contractor I U � Address 3� License No.C+/,,�,-�7(4/Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ 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 El Industrial EJ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications M Public F1 Other 11 Delta Depth of Grout Seal Type of Grout irrigation _..Approx. Depth t II Eastern Surface Seal Installed by - Repair Work Done ❑ Type of Pump '/ s2_ H.P. State Work Done Well Destruction ❑ Well Diameter Sealing f� Sealing Material (top 50') Depth �/rf Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION l l REPAIR/ADDITION 1 I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) 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. 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 F;-inflation Property Line SEEPAGE PITS l 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 Di§trict. 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 pe n in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the f low g: "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 ali rnia." The app st call for all ire d inspe ons. Complete drawing on r er a fide. Signed X Title: Date: �� M USE ONLY A�p ( U- 13-9 4rea Applic ' n Accepted by v"' — Date _` 1 _ ,. .�. Pit r Gro Inspection by Date I t7- Final Inspection by ^�®^- J^ Date 1 Additional 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 MOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT"NO. INFO t l +.EH13-241REV.)ixs) � EH 14-26 —3