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APPLICATION FOR PERMIT I.1 AN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 "MIT EXPIRES 1 YEAR FROM DATE ISSUED pMEryT A E�FERMIY/SER�►CES (Complete in Triplicate) cation is madlecn'compl ante writhdSanoJoaqu nthe San County OrdinaJoaquin lnce Nto.549 for sewage or h District for a permit No. 1862 for cwell/pump t and/or inend the Runes and all the work IR Regulations of theSan n described.This l Joaquin Local Health District. �zo 7� ^ PM Job Address City Lot Size pp A Phone Owner's Name / Q/ rAddress &a 76 9/-6� 2 9 Q /� /�/�`'� / �a /6 AL3?3 Phone Contractor �� " �`---�' Address 1`b License No TYPE OF WELL/PUMP: NEW WELL 11WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK -SEWER LINES DISPOSAL FLD. PROP. LINE O FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE , TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS V ❑ Industrial '- .tj Open Bottom ❑ Manteca Dia. of Welt Excavation Dia. of Well Casing Ui;Dgmestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications n Public ❑ Other C1 Delta Depth of Grout Seal Type of Grout — I I Irrigation _Approx. Depth�I I/Eastern $ ace Seal Installed by - r Repair Work Done ld Type of Pump G H.P. / State Work Done Well Destruction ❑ Well Diameter Sealing,Material ROP1501 Depth Filler Material (Below:501 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I 1 IN a septic system permitted if public sewer is - - - available within 200 feet.) 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.11Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. B Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size -- Number SUMPS L1 Distance to nearest: - Well Foundation Property Line 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 rules and regulations of the San Joaquin Local Health D13trict. 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- tion laws of California." The applica ust allfor ll fequi d inspections. Complete q drawing on reverse side. Signed X, 7r1`, L4itle: Date: O(T oIJOP FOR PARTMENT USE ONLY Application Accepted by 12v (4/x Date 6 Area Pit or Grout Inspection by Date Final Inspection by o Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 623-7104 ❑ Tracy 635-6365 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AM UNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. INFO a_EI}21(REV.vx51 a S ES 141a —