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Y APPLICATION FOR PERMIT E SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. H AZE`T ON AVE., STOCKTON, CA Telephone (209) 466-6781 r PERMIT EXPIRES T YEAR FROM DATE ISSUED (Complete in Triplicate) cation is lof install the work is apPI madec incompliance with h Sano the Joaquin Countyn J OrdinanceOrdinanuin Local ce No.549 for sewage o ealth District for a permit No. 1862 for welltlpump and the Runes and herein Regusations of tthe San l Joaquin Local Health District, I' City KYV • Lot Size PM + Job Address � � © � �1"� -'�- l- i I� 00-51506:& �f r Phone G Owner's Name Address 7 f11 Address License No. Phone_ Contractor TYPE OF WEL'LIPUMP: I�. NEW WELL L1 WELL REPLACEMENT 171 OTHER L1 C PUMP INSTALLATION ❑ SYSTEM REPAIR ElOTHER 1-1 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE i FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL OBLEM.AREA— -CONSTRUCTION SPECIFICATIONS ► Dia. of Well Casing t ❑ Industrial ❑ Open Botta ❑ anteca Ria. of Well Excavation Type of Casing Specifications ❑ Domestic/Private 03.Grav ack ❑ Tr y, YP g iType of Grout 1 Public ❑IOther 17 Delta Depth of Grout Seal i I I Irrigation !�..Approx. Depth l I Eastern Surface Seal Installed by iH p I State Work Done Repair Work Done L1 Type of Pump � Well Destruction ❑ Wrell Diameter Sealing Material (top 50') r Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I]j REPAIR/ADDITION Ll DESTRUCTION (vo septic systhin m rented it public sewer is O I Installation will serve: Residence X Commercial— Other p �N Number of living units: Number of bedroomsp Character of soil to a depth of 3'feet: Water table depth SEPTIC TANK I Type/Mfg i Capacity No. Compartments Method of Disposal PKG. TREATMENT PLT. ❑� \ I r Distance to nearest: i Well Foundation Property Line kLEACHING LINE 01 No. & Length of lines - Total length/size FILTER BED ❑ Distance to nearest: Well_ Foundation Property Line " (� 1 SEEPAGE PITS I I Depth `Size _ Number a�\ SUMPS ❑F Distance to nearest: Well Foundation Property Line �} DISPOSAL PONDS ❑I 1 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 JSan Joaquin Local Health District. Home owner or licensed agent's signature certifies the following: "1 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." 11. The applica must call for all reAired inspe tion mplate drawing on r e side. �y Signed X I�r' ^�-� Title: �� 'P date: FDR PARTMENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection by;l Date Final Inspection by Date h Additional Comments: ❑ 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 tZ]INT� REMITTED CKRECEIVED eY DATE PERMIT'NO. FEECASHlNF yy�(,+ EH 13-241REV.t `� `�� EH 14-26 .IM