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APPLICATION•FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE I ON AVE., STOCKTON, CA Telephone (209) 466 6781 PERMIT EXPIRES.1 YEAR FROM .DATE ISSUED (Complete in Triplicate). - c f Application is hereby made to the San Joaquin Local Health District for a permit to construct well/pump install the work herein described.TMs application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for welllpump and he Rules and Regulations of the 5 oaquin Local Health District. t - C Lot Size / C/ 1 PM_ ity, Job Address IIIP IF _. Phone. rr Owner's Name 4. �Addr nse No. t}i , Phone v Contractor's Name DESTRUCTION ❑ TYPE OF WELL/PUMP: NEW WELL ❑ WELL R PLACEMENT ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ SEWER LINES DISPOSAL FLD. PROP.SL'INE DISTANCE TO NEAREST: SEPTIC TANK PITS/SUMPS ., FOUNDATION AGRICULTURE WELL OTHER=WELL INTENDED D USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS pia. of Well Casing ❑ Open Bottom ❑ Manteca Dia. of Well Excavation r ❑ industrial F ► Specifications ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing ❑ pelta Depth of Grout Seal Type of Grout Public ❑ Other � + ❑ Irrigation _..J4pproxi Depth ❑ Eastern Surface Seal Installed by H.P. State Work Done + Repair Work Done El Type of Pump Sealing,,Material (top 501 f Well Destruction ❑ Well Diameter Y. Depth Filter Material f Belo I CTION ElTYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUaNvailabperwit in 200 feett�ed if public sewer is I k s ', ' 1 �w Installation will serve: Residence ! c=ommercial_ Other j Number of living units: _L_ Number of bedrooms *r--•-', r Water table depth Character of soil to a depth of 3 feet: . No.-Compartments; SEPTIC TANK ❑ Type/Mfg Capacity 1 n �� Method of Disposal PKG. TREATMENT PLT. ❑ �/F, I Foundation ! Property Line I Distance to,nearest:' Well ; x t' s:. F LEACHING LINE No& Length of lines (J Total length/size Property Line FILTER BED 13Distance to nearest: Well Foundation . I x�d X fVumber Size SEEPAGE PITS ❑ . Depth A 4 _ Property Line r SUMPS ❑ .Distance to nearest: Well - Foundation ' i DISPOSAL PONDS ❑ I l hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, an rules and regulations of the San Joaquin Local Health District. Nome 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 signature shah not employ any 'to become cert'�es the following:person in such manner"I certify thata n the performancect to workmanrS of he work for which this-compensation s issuedof ,fornia." Contractor's I shall employ perrsonslsubject to workmantls sub-contracting 4 tion laws of California." The applicant mu c for al required i ions. Complete rowing on re side. Date,; Title: j•. Signed FOR DEPARTMENT USE ONLY , w Date Ste" �— 5_. Area O r Application Accepted :4 byI Final inspection by 1j Pit or Grout inspection by Date Date Additional Comments: e ❑ Stk 466-6781 ❑ Lodf, 369-3621 EI 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 CK PERMIT'NO• FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE INFO + Ex 1344 IREv.101831 EH 1426 ��