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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 ;P€RMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) 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, or No. 1862 for welllpump and the Rules and Regulations of the San Joaquin made in compliance with San Joaquin County Ordinance No.549 for sewage Local Health District. Job Address (5 � Ci Lot Size PM !�J , Owner's Name Address I.CJ Contract � Rhon 1 f Addres� ~ 63� License��Z Phont � TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT L1DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. NE FOUNDATION AGRICULTURE WELL 0 L PITS/SUMPS INTENDED USE TYPE OF.WELL PROBLEM AREA CO TION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Mante _,—Dia. of Well Excavation Dia. of Well Casing PJ ❑ Domestic/Private ❑ Gravel Pack racy Type of Casing Specifications i7 Public ❑ Other , U1 Delta Depth of Grout Seal Type of Grout �. I i Irrigation Approx. Depth l',I Eastern Surface Sell Installed by - ' -t `��+ _ ? Repair Work Don Type of Pump H.P. State Work Done Well Des ton ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I f "DESTRUCTIO (No septic syit m rmiitted if public sewer is avat i Installation will serve: Residence Commercial— Other ; Number of living units: Number of bedrooms Character of soil to a depth of'9 feet: Water table depth SEPTIC TANK ❑ * Type/Mfg! - Capacity` Y No, Compartments i J+ F.� PKG. TREATMENT PLT. [ a Method of Disposal Distance to nearest:- Well Foundation v« f Property.Line LEACHING LINE L7 NO. & Lerigth of lines Total length/size C- FILTER BED ❑ Distance:{o nearest: Well Foundation"'" - �- Property Line SEEPAGE PITS l i Depth f Size Number I ,y SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ ' i I hereby certify that I-have prepared this application and that the work will be done in accordance with San Joaquin c6unty.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 iri 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." The applican ust call for all required inspections. Complete drawing on revers ide. Sign Title: Date: p T.��Date Application Accepted by Area Pit or Grout Inspection by tit Date 5 Final Inspection by Date ^ Additional Comments: 0 ❑ Stk 466-6781 ❑ Lodi 369W1 ❑ 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 F` FEE AMOUNT DUE AMOUNT REMITTED CKV CA H RECEIVED BY DATE jFEI�NO, INFO +.EH 13-241HEV.1iw51 3Jov EH 14-26 k._