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?- APPLICATION FOR PERMIT N SAN JO AQUIN LOCAL HEALTH DISTRICT T to 1601 E. HAZEL ION AVE., STOCKTON, CA Telephone (209) 468-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) he+eh made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This application is Application Is y . 1862 for welilpumP and the Rules and Regulations of the San Joaquin PP or No 549 for sewage made in compliance with San Joaquin County Ordinance No. 9 Local Health District. °1 � CPM ity, Lot Size Job Address ■) E. Owner's Name Address Phone L4N ContractorAddressicense No. PhaneTYj'E OF WELLIPUMP: WELL�❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ i DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER;WELL PITS/SUMPS Il INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom CJManteca Dia. of Well Excavation Dia. of Well Casing Type of Casing _ Specifications 'domestic/Private ❑ Gravel Pack ❑ Tracy Type of Grout . I"1 Public 171Ot e I1 Delta Depth of Grout Seal YP - I ( Irrigation I 7 ,, prox. Depth I Eastern Surface Seal Installed by Repair Work Done L3Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing.Material atop 501 Depth I Z Filler Material [Below 501 T TYPE OF SEPTIC WORK: NEW INSTALLA ION 171 REPAIR/ADDITION l 1 DESTRUCTION 1 1 iNo septic system hin m rented it public sewer isava �\ Installation will serve: Residence— Commercial— Other t Number of living units: Number of bedrooms I , Water table depth Character of soil to a depth,of 3 feet: „ ❑ iType/Mfg Capacity No. Compartments SEPTIC TANK ' Method of Disposal i PKG. TREATMENT PLT. ❑ ` Distance to nearest: Well Foundation Property Line 4 i 1 LEACHING LINE ❑ ..No. & Length of lines Total length/size 'i FILTER BED ❑ '� Distance to nearest: Well Foundation Property Line SEEPAGE PITS I 1 Depth Size Number SUMPS L1 Distance to nearest: Well_ Foundation Property Line ,I DISPOSAL PONDS ❑ 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 •i 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, l 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- 1' tion laws of California." The applicain ust cal or all required inspectioris. Complete drawing on reverse Sid Signed X Title: 1 Date: I ��OR DEPARTMENT USE ONLY I Application Accepted by I 4 Date Area L 2— !� Date�G Pit or Grout Inspection by Date Final Inspection by j Additional Comments: i� ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ 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 :i CK RECEIVED BY DATE PERMIT'NO. !° FEE AMOUNT DUE AMOUNT REMITTED CASH INFO r �� a +.EH 13 --3624(REV.7�w 51 \ /0 � �,.] � EH 14.28 J