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APPLICATION•FOR PERMIT I SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. rHAZEL T ON AVE., STOCKTON, Ct,, Telephone (209) 466-6781 E PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Appli /or install the work herein , This cation is madec ntion is heieby ade comp ante with San oJoaqu nthe nCounty Ordinance No. 549 for sewage or uin Local Health District for a permit 1862 for cwell/pump and the Runes and Regulations of he San l Joaquin Local Health District. , I City Lot SizePM fJ Job Address ; Owner's Name Address Phone r No. hone a-3-0- Contractor TYPE OF WELL/PUMP. NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FL PROP- LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS " ❑ Industrial El Open Bottom El Manteca Dia. of Well Excavation Dia. of Wel{ Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications t _ 1"1 Public Cl Other 171 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 501 , TYPE OF SEPTIC WORK: NEW INSTALLAT DN l REPAIRIADDITION i I DESTRUCTION I I Mo septic system permitted if public sewer is . available within 200 feet.l Installation will serve: Resident's Commercial_ Other y o)` Number of living units:.AZ___ Number of bedrooms T-- CharaFter of soil to a depth of 3 feet: JN� ter table depth SEPTIC TA3a1K LlType/Mfg """Ca`pai if ' :-Cbinpartments PKG. TRE&MENT PLT..❑ Il�ethod of D. al Distance to nearest: Well Foundation. ty)Line Proper r - LEACHING LI i ❑ No. & Length of lines "^ Total length/size _ FILTER BED ❑ Distance to nearest: Well_ ..r Foundation Property Line__7 SEEPAGE PITS l 1 Depth i Number MPS Cl Distance to nearest: Well Foundation__. _lam— Property Line_ ,— ' DISPOSAL PONDS ❑ �r 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 i. tion laws of California." The appltcant u t cal r al requir in pec ions. Complete rawing on r se side. } Signed X Title: Date: FOR DEPARTMENT USE ONLY ' Application Accepted by Date Area—��-- Pit or out Inspection by Dated Final Inspection by Date a Additional e.m If eft s: 6!e2 c2 CZ&A ❑ Stk 466-6761 ❑ Lodi 369-3621 ❑ Manteca 7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 r a FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. INFO 1 + EH 13-24(RW I/ b) EH 14-26 - ¢