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SAN JOAQUIN LOCAL HEALTH DISTRICT' �`- APPLICATION FOR PERMIT ENVIRONMENTAL HE ALTH D.WISiON ( SAN JOAQUIN LOCAL HEALTH DISTRICT SPECIAL PERmiT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED F (Complete in Triplicate) i2 t to /or install the work . This cation is madeinApplication `iante wieieby the to the San Joaquinuin Local Ordinance No.549 for sewage orealth District for a 'No 1862 forcwellldpump and the Rules and IR Regulations of the San Joaquin 4 � made in co p 1 Local Health District. 3'76 r City Lot Size PM Job Address ! wr Address �" "` r DC Phone �'�y Owner's Name - Llaj— Tar l hone Contractor k,�� ddress License No. � 3 TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER 171 DISTANCE TO NEAREST: SEPTIC TANK — SEWER LINES Z+ — DISPOSAL FLD- PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS i INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS i +Industrial F El Open Bottom El Manteca Dia. of Well Excavation Dia. of Wr. ell Casing ❑ Domestic/Private YCiravel Pack ❑ Tracy Type of Casing Specifications7Z F1 Public 01he0?�� ❑ Delta Depth of Grout Seal �/ Type of Grout I I Irrigation Approx. epth l I Eastern Surface Seal installed by Wye — Repair Work Done ED /Type of Pump .�G� H.P. State Work Done Well Destruction ❑ Weil Diameter Sealing Material Itop 501 Depth Filler Material {Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIRIADDITION f I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 ieet.i 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 Foundation Property Line SEEPAGE PITS N Depth Size Number SUMPS 1-1 Distance to nearest: Well Foundation Property Line I DISPOSAL PONDS ❑ F 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 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- t tion laws of California." The applicant m t or all requ' i io . Complete drawing on arse ide. I f t Signed X Title: k Date: FOR DEPARTMENT USE ONLY Application Accepted by Date + Area Pit or Grout Inspection by ' Date 77 Final Inspection by 5' .� — Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 623-7104 [I Tracy 835-63$5 Applicant • Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 i FEE ;AMOUNT DUE AMOUNT REMITTED ASH RECEIVED BY DATE PERMITIVO. INFOEH13-241REV.1/n5)EH 1428