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APPLICATION FOR PERMIT PAYMENT SAN JOAQUIN LOCAL HEALTH DISTRICT RECEIVED 1601 E. HAZELTON AVE., STOCKTON, CA AUG � � -Telephone {209} 466-6781 13 SAN )OAQUIN COUNTY EXPIRES 1 YEAR FROM DATE ISSUED PUBLIC HEALTH S0VICES (Complete in Triplicate) ENVIRONMENTAL HEAL1'Fi DIVI,4,N 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 made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for welUpump and the Rules and Regulations of the San Joaquin Local Health District. Job Address i City Lot Size PM Owner's Nam Address t�[_`�_ :g Phof5--! UMP&WELL SIERVICE R0.8Q 602 LINDEN, CA 95 Contractor sS License No. QM4Z Phone / TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK. SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ .INTENDED USE- TYPE OF WELL PROBLEM AREA CONSTRUCTIOWSPECIFICATIONS f .- ❑ Industrial ❑ Open Bottom ❑ Manteca Dia, of Well Excavation Dia. of Well Casing I� Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications M Public I-1 Other ❑ Delta Depth of Grout Seal Type of Grout _ I Irrigation u _..Approx. Dept I Eastern Surface Seal Installed by _ Repair Work Done 11 Type of Pump =>W2 H.P. 1 S State Work Done Well Destruction ❑ Well Diamet I Sealing Material (top 501 Depth } Filler Material {Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION l I DESTRUCTION 1 I (No septic system permitted if public sewer is ' available within 200 feet.) Installation will serve: Residence {Commercial Other Number of living units: Number of bedrooms t Character of soil to a depth of 3 feet: ' Water table depth r SEPTIC TANK ❑ Type/Mfg t Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line 4 LEACHING LINE ❑ No. & Length of lines Totat length/size i FILTER BED 0 Distance to nearest: Well Foundation -Property Line SEEPAGE PITS I 1 Depth Size Number SUMPS L� 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 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- tion laws of Calif is " } I The applicant m I for all required ins ti s. plate drawing on reverse side. 4 Signed X i Date: r ' R DEPARTMEN7tUSE ONLY Application Accepted byDate Area Pit or Grout inspection by Date Final Inspection 6y to / r 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 i t INFO AMOUNT DUE [MOUNT REMITTED CK 4 CASH RECEIVE(]BY DATE PERMIT NO. +.EH 13241REV.I/N5Y EH 14-28