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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL.HEALTH DISTRICT 1601 E. HAZELTON~AVE., STOCKTON, CA Teleph6ne{209) 466-6781 PERMIT EXPIRES 1'YEAA FROM DATE ISSUED. n y (Complete in Triplicate) SES .. Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work hereiri described. This application is or No. 1862 for well/pump and the Ryles and Regulations of the San Joaquin made in compliance with San Joaquin County Ordinance No.549 for sewage Local Health District. ;' ' /l.� ,t! �•� / / Cit r r. . $.�j PM r Lat Size ✓ Job Address ;, u t;, ♦ - f f-�r - �fT.:.• .. ... 'I ?ids. L� 7- Owner's Na mL�" � - U/1l :Address ". � Phone / Contractor Address_ License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER •�] DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO.-- PROP. LINE FOUNDATION AGRICULTURE WELL _ OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL, PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Pia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal _ Type of Grout-- F_ rout❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by-- Repair y_Repair Work Done ❑ Type of Pump :" H.P._ State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 - G Depth _ Filler Material (Below 601 TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION DESTRUCTION$QNoseptic sh tem emitted if public sewer is availabInstallation will serve: Residence_ Commercial Other Number of living units: —_ Number of bedrooms y Character of soil to a depth of 3 feet: �Ff Water table depth SEPTIC TANK Type!Mfg Capacity O No. Compartments PKG. TREATMENT PLT. ❑ / ;Method of Disp Distance to nearest: Well �O.0 _toundation—�_�— Property Line y r LEACHING LINE ❑ No. & Length of lines — 4 �- TQta"I fengthlsu FILTER BED Distance to nearest: Well G Foundation "�_/ Property L t SEEPAGE PITS ❑ Depth Size_ Number v SUMPS ❑ 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."Contractors hiring or sub-contracting signature for which this permit is issued,I shall employ persons subject to Workman's compensa- cert'rfies the following: "I certify that in the performance of the work tion laws of California." ` The applies ust call for 1 aqui- pe s. Comdata drawing on reverse side. p Tit e: Date: Signed r / FO DEPARTMENT USE ONLY l /y/6C:�'S�� _ Application Accepted by - res V r S Pit or Grout Inspection by Date Final Inspe n b Data Additional Comments: O Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 _. Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazatton Ave., P.O. Box 2009, Stk., CA 95201• 1 FEE AMOUNT DUE AMOUNT REMITTED C RECEIVED BY DATE? , PERMIT'N0. INFO 4 E"1 3-24(REV.l:B51 1 13 —• ,�.O �.sv w- �� EH 1426 _ __