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ON FOR PERMIT .` APPLICATION SAN JOAQUIN LOCAL HEALTH DISTRICT `w 1601 E. HAZEL.T ON AVE., STOCKTON, CA Telephone {209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) 549 for sewage or No. 1862 for well/PUMP and the Rules and Regulations of the San Joaquin 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 1s made in compliance with San Joaquin County Ordinance x Local Health District. y�� PM b K City C Lot Size { Job Address j Phone p J J Address { Owner's Name i L License No. Phone_ 13 x Address i Contractor WELL REPLACEMENT ❑ DESTRUCTION ❑ NEW WELL ❑ OTHER ❑ TYPE OF WELL/PUMP: SYSTEM REPAIR ❑ f PUMP INSTALLATION ❑ DISPOSAL FLD. PROP. LINE SEWER LINES �-- t DISTANCE TO NEAREST: SEPTIC TANK AGRICULTURE WELL OTHER WELL_.-- PITS/SUMPS FOUNDATION rOF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS INTENDED USE TYPE —�� Dia. of Well Casing Dia. of Well Excavation Ll industrial L) Open Bottom ❑ Manteca Specifications ❑ Gravel Pack Ll Tracy Type of Casing _ ❑ DomesticIprivate Type of Grout l ❑ Other ❑ Delta Depth of Grout Seat ['1 Public Surface Seal installed by I I Irrigation _..Approx. Depth [ I Eastern State Work Done— H.P. Repair Work Done ❑ Type of Pump ---- Sealing Material (top 50'1 Well Destruction F1 Well Diameter -- -- Filler Material IBeIoW 50') Depth TYo E PE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR!AD l I DESTRUCTION (Nailabpelw thin 200 feet.)ted it public sewer is " Installation will serve: Residence— Commercial— Other ! Number of living units: Number of bedrooms Water table depth Character of soil to a depth of 3 feet: Capacity No. Compartments SEPTIC TANK ❑ Type/Mfg Method of Disposal r PKG. TREATMENT PLT. ❑ Distance to nearest: Well Foundation Property Line Total length/size LEACHING LINE ❑ No. A Length of lines Property Line FILTER BED ❑ Distance to nearest: Well Foundation Size Number ' SEEPAGE PITS I I Depth Property Line f SUMPS Ll Distance to nearest: Well Foundation 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, an rules and regulations of the San Joaquin Local Health Oi'strlct. 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 of 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." L The applicant must call for all required inspections. Complete drawing�reverAse side., Date: signed X sl_ 6�—� Title: FOR DEPARTMENT USE ONLY ' s Date Area Application Accepted by ` Pit or Grout Inspection by Date Final Inspection by Date-L Additional Comments: ❑ Stk 466-6781 0 Lodi 369-3621 fl [Manteca 823-7104 ❑ Tray 835-&385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazeltan Ave., P.O. Box 2009, Stk., CA 95201 ffIN E CK RECEIVED By DATE PERMIT-NO. AMOUNT DUE AMOUNT REMITTED CASH O "l, 1 �Lif, +.EH 13-24 1pEv.1/85) "'t EH 14-2e