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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA ` Telephone 12091 466-6781 r, z, PERMIT EXPIRES 1-YEAR FROM DATE ISSUEDf {Complete in Triplicate) 9San cre T1` lication is he Joaquin Application is hereby made to the San JoIt�aquirOLd ordinance No.549 for sewage or permit No 1862 forconstruct well1pump and the Rules and r�e ti?� � � made in compliance with San Joaquin Co ty it Local Health District. Cityr Lot Size PM Job Address �* Phone- Owner's Namelr Address License No. Phone Address F Contractor r TYPE OF WELL/PUMP: EW WELL 171 WELL REPLACEMEN ❑ DESTRUCTION ❑ PUMP INSTALLATION�i SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELLT PITS/SUMPS 4 INTENDED USETYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing ❑ Industrial R'Open Bottom ❑ Manteca Dia. of Weil Excavation Specifications ❑ Domestic/Private ❑ Graver Pack ❑ Type of Casing Tracy Type of Grout M Public ❑ Other ❑ Delta Depth of Grout Seal _ II'Irrigation --Approxi Dept 1.1 Eastern Surface Seal Installed by r H P �it., 6WO') State Work Done Repair Work Done ❑ Type of Pump ♦, { Well Destruction ❑ Well Diameter _ �+...— Sealing Ma 'tel _ CSD Filler Material (Below 501 'I TYPE OF SEPTIC WORK: -NEW—INSTALLATION 11 REPAIR/ADDITION l 1 DESTRUCTION ! I aNailabetrwthin 2001eeft,ed if public sewer is Installation will serve Residence t Commercial Other !Number of,living units: Number of bedrooms r Water table depth Character of soil to a depth of 3 feet, No. Compartments SEPTIC TANK ❑ Type/Mfg Capacity - Method of Disposal PKG. TREATMENT PLT. ❑ Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line ----------------- SEEPAGE PITS I I Depth Size Number 1l. Distance to-nearest: Well Foundation Property Line, _ . . SUMP-S : . r.. T 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: -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 to workmanompensa- signature ' certifies the following: " ce i y that in the performance of the work for which this permit is issued, I shall employ persons tion laws of California : The applicant must for I require in ions:Complete drawing on reverse side. A Title: Date: Signed X j F FOR DEPARTMENT USEO Y Da Are v Application Accepted by Pit or Grout inspection by Date Final Inspection by Date i Additional Comments: C1 Stk 466-6781 1-1Lodi369.3621 El Manteca 823 7104 EJ Tracy 835 6385 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 Applicant .- Return all copies to: Environmental Health Permit]Services FEECK RECEIVED BY DATE PERMIT NO. AMOUNT DUE AMOUNT REMITTED CASH INFO ♦ EH 13-24 IREV.i/e 5} O y EH 14-28