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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1'YEAR FROM DATE ISSUED -(Complete in Triplicate) /or install the work herein described. This caflon is I. Application is he�by made to the nCou Joaquin ordinance No. 549 for sewage or ealth District for a permit 1862 forcwellapump and the Rules and Regulations of the San l Joaquin made in compliance with San Joaquinh Local Health District.. Job Address — City b Lot Size PM Owner's Name Address Phone �l.L 1, I TA 1� Contractor Address 10o�License No. 57L1 Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER ❑ 61—STANCE TO NEAREST:'SEPTIC TANK SEWER LINES ...� DISPOSAL FLD.- �""PRdP.L1NE" FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Ll Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing "Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications t Type of Grout--- (1 rout — t ("1 Public ❑ Other Fl Depth of Grout Seal I I I Irrigation _.-Approx. Depth 11 Eastern Surface Seal installed by State Work Done Repair Work Done ❑ Type of Pump uQ H.P. Well Destruction ❑ Well Diameter z� Sealing Material (top 50') Depth Filler Material (Below 50') -- TYPE OF SEPTIC WORK: NEW INSTALLATION I] REPAIR/ADDITION 1 I DESTRUCTION I 1 lNo septic system permitted if public sewer is available within 200 feet.i Installation will serve: Residence_ Commercial— Other Q Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth N 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 ❑ "Distan`ce to neatest:"Well` �"""Foundation Property DISPOSAL PONDS ❑ I hereby certify that l have prepared this application and that the work wilt 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 folio 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 Cal `- Theappl ant call for all req ire inspec i ns. Complete drawing o rev se side. Signed X Title: Date: L DEPART ENT USE ONLY Application Accepted by Date Area ` Pit or Grout Inspection by D e Final Inspection by� 1Date Additional Comments: ❑ Silk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health PermitlServices 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED INFO SH RECEIVED BY DATE PERMIT NO. // ��.7y i, s.EH 13-24 tRE'V.i/R 51 'D f� I c,Jit EH 1♦-26