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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) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This application is Applica made e or No. 1862 for welllpump and the Rules and Regulations of the San Joaquin compliance with San Joaquin County Ordinance No.549 for sewag Local Health District. O City / Lot Size PM Job Address Phone,,Gv�` 76v A � / ddress , Owner's Nam fmay/ Nor Phone Contractor MygeitSa Address 1 NEW WELL El WELL REPLACEMENT ❑ DESTRUCTION ❑ TYPE OF WELL/PUMP: ' OTHER ❑ PUMP INSTALL SYSTEM REPAIR ❑ INSTALLATION SEWER LINES DISPOSAL FLD. PROP. LINE DISTANCE TO NEAREST: SEPTIC TANK PITS/SUMPS FOUNDATION AGRICULTURE WELL OTHER WELL INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS pia. vi Well Casing ❑ Open Bottom [-IManteca Dia. of Well Excavation ❑ Industrial Specifications El Tracy Type of Casing ❑ Domestic/Private ❑ Gravel Pack Cl Delta Depth of Grout Seal Type of Grout F-17ublic ❑ Other .Approx. Depth i I Eastern. Surface Seal Installed by I I Irrigation — State Work Done Repair Work Done ❑ Type of Pump H.P. Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material-(Below 50') i TYPE OF SEPTIC WORK: NEW INSTALLATION I REPAIRlADDITION I I DESTRUCTION I i availablelwthin 200 feet.)c system if public sewer is f Installation will serve: Residence— Commercial _ Other Number of living units: Number of bedrooms Water table depth Character of soil to a depth of 3 feet: No. Compartments 0 Type/Mf Capacity SEPTIC TANK g Method of Disposal t PKG. TREATMENT PLT. ❑ Well } Foundation Property Line I Distance to nearest: Total length/size LEACHING LINE ❑ No- & Length of lines Property Line i FILTER BED ❑ Distance to nearest: Well Foundation I • Number ~ SEEPAGE PITS I I Depth Size SUMPS L-1Distance Property Line Distance to nearest: Well ; t DISPOSAL PONDS ❑ f r I hereby certify that V 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- k g:' f tion laws of California." t r The applicant must II fo II r fired inspection omplete drawing on reverse side. t �f��ir/afrio'r� Date: � Signed Title: �� M R D ARTMENT USE ONLY --� Date Area Application Accepted by Data Fi al Inspection by Date /` f r Pit or Grout Inspection by Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies 10: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 CK RECEIVED BY DATE PERMIT NO. FEE AMOUNT DUE AMOUNT REMITTED CASH INFO r C ` gq +.EH 13-24 IREV.I/ EH 14.218